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unPAUSED with Dr. Mary Claire Haver
Menopause, Hormones and Women’s Sexual Health with Dr. Rachel Rubin
01:47:12
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- [00:00]
Dr. Rachel Rubin
And let me just say, as a urologist, nobody expects me to take care of all of a man's health needs. No man comes to see me for all of his medical care and he shouldn't. He should have several different doctors that take care of him. So the mere fact that we have OB GYNs and they are expected to take care of a woman once a year for 15 minutes with your legs up in stirrups and that's medical care for the rest of your life is unconscionable. And so women have to stop expecting expecting their OB gyns to know everything about their bodies because they simply don't. Why does an OBGYN know about your heart? I don't know about a man's heart. As a urologist to the level that OB GYN is expected to know about breast cancer and heart disease and bone health, it makes no sense.
- [00:51]
Dr. Mary Claire Haver
The views and opinions expressed on Unpaused are those of the talent and guests of the alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment. Today's guest is not only one of the most influential voices in sexual medicine, but someone I'm lucky enough to call a friend. Dr. Rachel Rubin is a board certified urologist and a nationally recognized expert in sexual medicine. She is one of the few physicians physically fellowship trained in both female and male sexual health and she serves as an Assistant Clinical professor of Urology at Georgetown University. She has shaped the field through her leadership as the former Education Chair and current Director at large for the International Society for the Study of Women's Sexual Health. She also serves on the editorial boards of the Journal of Sexual Medicine and the Video Journal of Sexual Medicine, and she is a contributor and vocal advocate TO for the 2025American Urological association guidelines on the Genital Urinary syndrome of menopause. Her work extends far beyond the clinic. Rachel founded the Sexual Medicine Research Team, a collaborative initiative advancing clinical research in sexual health. Their work has pioneered our understanding around advocacy and around clitoral adhesions, genital urinary syndrome of lactation, and many other rarely discussed sexual health conditions. But before I ever knew the full depth of her credentials, I knew her fire. I knew her honesty. I knew her relentlessness. Rachel and I have shared stages, compared notes from clinic, and cheered each other on through the exhausting work of changing healthcare for women. I trust her not just as a clinician, but as an ally and truth teller. Her advocacy has been amplified through her deeply personal experiences. During the July FDA panel on Women's Health and Hormone Therapy, Rachel spoke openly about her mother's challenging prolonged ICU stay and her difficulty accessing local vaginal estrogen to prevent urinary tract infections and sepsis. She used this story to show the deep harm the outdated and incorrect FDA warning labels placed on patient care and physician knowledge. That experience lit a fire in Rachel that has fueled her entire career. It is the reason she fights outdated regulations. It is the reason she pushes for better training. It is the reason she is tireless in making sure no woman is ever left in the dark about her own anatomy, her hormones or her sexual health. Rachel is one of the rare physicians who combines rigorous scientific expertise with compassion, clarity and courage. She works, teaches, race researches, publishes, advocates and educates with a singular mission to bring women the evidence based care they have deserved for generations. I love her fire. I love her honesty. I love her commitment to doing the hard necessary work of rewriting Women's Healthcare. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified Menopause practitioner. I'm also an adjunct professor of Obstetrics and Gynecology at the University of Texas Medical Branch of welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. January for me is always about simplifying, not starting over. I want products that work with my body, fit into real life, and don't make things more complicated. That's why I use Primally Pure. Their natural deodorant is one of those essentials that truly makes a difference. It keeps me feeling fresh throughout workouts and long days. I've also added their body butter into my routine. It's a simple way to care for my skin, keep it nourished, and maintain healthy habits without adding anything extra to my day. Everything from Primally Pure, including skin, body, hair, baby and home products, is made with real, raw ingredients that support your skin over time. No shortcuts, no fluff, just clean essentials that make healthy habits feel effortless, especially with a busy lifestyle. Using simple, effective products like these makes my daily routine feel manageable, nourishing and intentional. It's a small way to take care of myself each day and feel good in a way that actually lasts. Use the Code unpaused to get 15% off your Primally Pure purchase. That's www.primallypure.com use code unpaused at checkout for 15% off your order. Big tax changes this year could mean a bigger refund. And Jackson Hewitt knows how to get you your biggest.
- [05:42]
Dr. Rachel Rubin
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- [05:48]
Dr. Mary Claire Haver
And since we know all the new tax codes, you could get thousands back.
- [05:51]
Dr. Rachel Rubin
Which would make you low key, loaded.
- [05:53]
Dr. Mary Claire Haver
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- [06:01]
Dr. Rachel Rubin
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- [06:09]
Dr. Mary Claire Haver
Welcome to Unpaused.
- [06:11]
Dr. Rachel Rubin
Oh my gosh, how cool that we're finally doing this.
- [06:13]
Dr. Mary Claire Haver
Oh my God. You are like, people don't know that we actually know each other. So when we're like, who do we have on the podcast? Your name was like at the top.
- [06:21]
Dr. Rachel Rubin
Oh my gosh.
- [06:21]
Dr. Mary Claire Haver
Like, they want to talk about sex, they want to talk about sexual health. And I'm like, I, I, I'm. And here we are doing it. Let's let our audience get to know you a tiny bit. Where are you from?
- [06:29]
Dr. Rachel Rubin
So I'm a little bit from all over. Was born in Ohio, moved to Connecticut, and grew up mostly in the Washington, D.C. area, which is where I am now. Medical training was in Boston, and my residency urology training was Also in Washington, D.C. i did one year of fellowship, a sexual medicine fellowship in San Diego. So I got to live in San Diego for a year, which is not terrible place to have your first baby. And I'm practicing in the Washington, D.C. area.
- [06:52]
Dr. Mary Claire Haver
O why urology for our listeners? Most women do not choose urology as a profession.
- [06:59]
Dr. Rachel Rubin
Yeah, every little girl dreams of being a penis doctor. Actually, it's part of a lifestream. It is kind of strange how I got here. Sometimes I wake up, I say, how did I end here? About 10% of practicing urologists are women. So we are a small but mighty group. We are very funny, we're very silly, and we can say as many bad words as we want. It's actually something we all like each other very much. But you're wrong. Urology is a fascinating field where you can take care of women. Nobody realizes this. You can take care of women. You can take care of women because.
- [07:31]
Dr. Mary Claire Haver
Women actually have kidneys and ureters and shocking.
- [07:34]
Dr. Rachel Rubin
Women have kidneys and bladders and genitals. And urologists are sex doctors. We care about quality of life. We care about sexual health. And people assume that their gynecologists know everything. About sex. And it turns out they don't. And so it was a really fun field where I didn't have to deliver babies and be up all night, and I could do women's health without being an obstetrician.
- [07:55]
Dr. Mary Claire Haver
You did a sexual medicine fellowship, which is rare as well.
- [07:59]
Dr. Rachel Rubin
Yeah.
- [07:59]
Dr. Mary Claire Haver
What was that like?
- [08:00]
Dr. Rachel Rubin
Yeah, I'm probably one of only a handful of people who can say that they're a sexual medicine doctor now. There are many people who practice sexual medicine, but these fellowships are rare, and we're hoping to build more. That's one of my dreams, is to have a fellowship. If I speak it now, I can put it into the world. But this, you know, my mentor is a guru. Amazing. You should totally have him on the podcast. This guy, Irwin Goldstein, who really pioneered men's sexual health and then realized, well, wait a minute, there's nothing for women. And so he pioneered this amazing organization called iswit, the International Society for the Study of Women's Sexual Health. ISS WSH. And he pioneered that over 20 years ago, around the time Viagra had come out. And it really has advanced the field of women's sexual health. His training is what I did. I trained with him. And you learn sexual medicine for men and women. You learn sexual medicine for everybody. And it really was the only fellowship up until a year or two ago, is the only fellowship that even acknowledged women's sexual health. There are a handful of us we call. We're the fellowship family. We call each other brother and sister. Now, there are two programs that have come out, OBGYN programs for women's sexual health. But that's it. You're talking about three programs in the last three years that even acknowledge women's sexual health. We have more than 27 for men's sexual health. And so the reason your doctor doesn't know about how to talk about libido, arousal, orgasm, or pain is no one ever taught them.
- [09:20]
Dr. Mary Claire Haver
I learned nothing. Like, literally nothing.
- [09:25]
Dr. Rachel Rubin
And say it louder for the people in the back, because it's not your fault. Fault.
- [09:29]
Dr. Mary Claire Haver
Right. I, I, I just graduated from my training program. I could deliver the shit out of a baby upside down, backwards, all in the middle of the night, one hand tied behind my back. Surgery. Like, I was trained so well how to take care of pregnant people, and that's important. I knew how to do a hysterectomy and basic gynecologic surgeries. I could do vaginal procedure, you know, remove a cyst or drain a drain, a, you know, infected area or whatever. But, like, so I graduate and I go into my clinical practice and I'm super excited. I hang up my shingle and I open the door and the women come in and if they're not pregnant, they're coming gynecology or their well woman and their checkups. And I cannot tell you how many times I would blank stare at a patient and feel horrified that I didn't know how to help her, that she was complaining of some type of sexual dysfunction that was affecting her life.
- [10:15]
Dr. Rachel Rubin
And let me just say, as a urologist, nobody expects me to take care of all of a man's health needs. No man comes to see me for all of his medical care and he shouldn't. He should have several different doctors that take care of him. So the mere fact that we have OB GYNs and they are expected to take care of a woman once a year for 15 minutes with your legs up in stirrups and that's medical care for the rest of your life is unconscionable. And so women have to stop expecting their OB GYNs to know everything about their bodies because they simply don't. Why does an OB GYN know about your heart? I don't know about a man's heart. As a urologist to the level that an OB GYN is expected to know about breast cancer and heart disease and bone health, it makes no sense.
- [10:58]
Dr. Mary Claire Haver
I absolutely agree. I, well, and then the other side thing is I go out to my, you know, my bosses who were older, seasoned, you know, OBGYNs and say, I've got Ms. Smith and you know, help. What, what do I say? What do I do? And now that I realize the platitudes that they were coaching me, you know, the dismissive condolences of oh honey, it's just your age or oh honey, go have some wine or oh, just relax or let's get you to a psychiatrist or something, or you know, just, just anything. But let's address the problem. What's going on? I never learned the framework of addressing sexual dysfunction until about, until I decided to open my menopause clinic.
- [11:36]
Dr. Rachel Rubin
And the magic is time. And I think our current healthcare system is not set up to give people what they absolutely need and deserve is time. Because your life, right, even a healthy person's life deserves more than a 10 minute visit once a year, right? You deserve someone who knows you, who, who, who listens to you, who can really know, you know, kind of what you want, what your goals are. And there no time for that in the current medical system. So it's kind of broken. What I wish is that doctors would say, hey, this is broken. I can't do this all today. Here's your options, or here's someone down the street who actually does this. And instead there tends to be more dismissal. Well, you must be crazy or it must be a psychological issue or you.
- [12:14]
Dr. Mary Claire Haver
Don'T love your husband or.
- [12:15]
Dr. Rachel Rubin
Yes. Or it's just a bad marriage or you're stressed because you have four kids. And yes, that's stressful. And it is that minimization. It's like death by a thousand cuts. And so women, they stop even thinking that they can have good sex or that they deserve good sex or that they even know who to act if they have a sexual problem.
- [12:31]
Dr. Mary Claire Haver
You had the unique perspective and I've had a few experts who take care of men and women on the show, and I've only taken care of women and delivered the baby boy, cut the cord and then handed it off. Okay, so the only penis I look after is one. But you had the perspective of taking care of women and taking care of men who come in with the exact same complaints. And you saw this huge dichotomy of how this, this was approached as far as sexual health.
- [12:58]
Dr. Rachel Rubin
I think we've actually been more successful at this because we're coming at this from the outside of, of ob GYN and saying, wait a minute, we don't do this. For men, everything is like, it's so much easier. Men, we can talk about quality of life. Men, we can do shared decision making. Men get to make choices for what they do with their body. The science, the rigor of science, the level of science and the discussions around science are so much easier when it comes to men's health versus women's health. The way we talk about women, you can't this, you absolutely should. You, you, you can't. It's not you shouldn't do this. It's you can't take this. This is a contraindication. You can't have this. In the men's health world, we're like, oh, you don't want prostate cancer surgery because you like your ejaculate. Let's work out a way that you can have it all and let's study it. We at Johns Hopkins and do multiple where we can just watch your cancer, see what happens because your ejaculate is the most important thing to you. That is real world high level urology medicine in 2025.
- [13:55]
Dr. Mary Claire Haver
And what happens on the female side of this.
- [13:57]
Dr. Rachel Rubin
The female side is if you even think about Having an atypical cell in your body that could be cancer. One day we have to castrate you. You can't even be near the word hormones. You can't even talk about hormones and your sexual health not on the list of things that we care about. And so how dare you even consider wanting an orgasm or pain, sex that's not painful because you're just lucky to be alive in 2025. Tell me I'm wrong.
- [14:20]
Dr. Mary Claire Haver
Prove me wrong. No, no, you're absolutely right. I mean, and it was literally, I was in that mindset of be grateful you're alive, your pleasure, your sexual health is. Is not even medically recognized or is. Is not considered to be a priority because I only treated women. And this is what the system taught me. This is what the books taught me. Like, we focus on every cell in her body that might become cancerous, and we make sure we don't do anything that could possibly lead to a cancer despite. And not taking into account any of her happiness or her wants or her needs or what her goals and desires are. And it wasn't until talking to you and. And people who are taking care of men going, wait a minute. We don't do this to men. We don't castrate men.
- [15:03]
Dr. Rachel Rubin
By and large, the risk benefit discussions are completely different when it comes to men versus when it comes to women. And we love. Okay, so I say this a lot, right? Parkinson's was a psychological disease until they discovered dopamine. Right. Schizophrenia. Right. Is a psychological disease until they discovered, you know, dopamine and neurotransmitters, like, all of these things. So erectile dysfunction was a psychologic disease until they. Nitric oxide, and it became a biological disease. And so all of women's health or sexual health tends to be, oh, it's all in your head. It's all psychological because nobody wants to study dopamine and blood flow and nitric oxide, and no one wants to figure out how to measure clitoral blood flow because the clitoris is internal. And nobody does the work. And everyone screams and yells in the world. There needs to be more research. We need more funding. We need more research. Who's gonna do it? If no one trains you how to do it? Right? If no one actually rolls up their sleeves and writes that IRB and writes the protocol and gets the funding and actually does the work, the research will never get done. So we can complain all we want, but you need human beings doing the actual work, which is not easy, and it's not funded. The NIH The NIH is not funding orgasm research, right? And so the, the, the, the people who, who, who, who fund research, sexual health is going to be the last thing that gets funded.
- [16:25]
Dr. Mary Claire Haver
I love that quote of the NIH doesn't care about your orgasm if you're.
- [16:28]
Dr. Rachel Rubin
A woman, if you're even men. They don't particularly care about men, actually. I will say, and I'll defend there, we, we have a long way to go in men's health too, and men's sexual health too. There is so much we don't know about orgasm for all beings. There's so much we don't know about ejaculate. There's so much, there's so many questions we have. And actually, even in the urology space, we've got erectile dysfunction and penile implants and that algorithm. It's pretty, you know, well established. There's certainly things we can do to improve, but, but the rare conditions. So I take care of a lot of rare male sexual dysfunction, the, what we call the weird and the wacky, the zebras, the complicated things. No one's taking care of these people either, and no one's studying it to the level that we need to be sitting at. All the sexual side effects of a lot of these medications that we're using, no one cares. And actually, these are the men who come to my clinic and they wait months and months to see me. And they come from all over the world and they are dismissed just like women are. They're the only patients who understand what women with sexual dysfunction or women with menopause or women with pelvic pain, they, they understand because they are also dismissed by the medical community.
- [17:31]
Dr. Mary Claire Haver
So most clinicians, and this is, myself included, I was obgyn, and I could not have drawn a clitoris, anatomically correct clitoris, until I saw the Gumby picture. And you're wearing the clitoris necklace. So for those of you on YouTube, she has a beautifully jeweled clitoris. This is what they look like. I only knew the top part. And I think of all the stitches I threw in the bulvo cavernosum, you know, repairing lacerations after delivery. And I was going right through these little legs on her necklace right here.
- [18:03]
Dr. Rachel Rubin
So it's really interesting. I'm obsessed with this concept of a word called homologues. Okay? Homologues are this idea that the head of the penis and the head of the clitoris are exactly the same thing. They're, they're, they're. We all form. We're the same. It's the same tissue. It's made. It looks the same under the microscope. There's a shaft of the clitoris that you can kind of feel if you go kind of beyond the head of the clitoris and the penis also there's the shaft, and then the penis splits into two, and it goes. It has these things called crura, which are these legs that go all the way down to your butt bones. Okay. Clitoris also goes all the way down to your butt bones. And so this idea, the scrotal skin is the same as the labia majora, the line that goes down the center of a penis and a scrotum. It's the same as the labia minora. It's so fascinating. The male urethra, the tube that men pee and ejaculate through, is the same as this most important tissue in the world, which is called the vulvar vestibule, which is the opening around the urethra where women have pain with sex, which is so common. And we see all the time, and no one examines properly. And so we see these homologues. And they're important because how you experience pleasure is important. And so everyone knows, everyone who's ever pleasured a penis knows that you don't just lightly touch the head of the penis to get pleasure. You don't touch the man's thigh to get pleasure. It's kind of this whole shaft thing. And there's a whole, you know, there's a whole thing. There's a whole organ there. And so when you teach women about their organs and their body parts, you have to tell them that this is just the head of the clitoris, which is like the head of the penis. There is a shaft, and there are these legs that are sort of beneath the skin and a little bit deeper and may require excess stimulation, vibration, more aggressive. Right. Like, so you have to really think logically about your anatomy and why you are or are not having pleasure. And so if a penis were buried and you couldn't access it with your hands or your mouth or vagina or whatever it was, how would you stimulate the penis? And it's kind of that question of, like, how do you stimulate a clitoris when you can only see the tip of the iceberg.
- [19:58]
Dr. Mary Claire Haver
Yeah.
- [19:59]
Dr. Rachel Rubin
And that's why the vibrator industry is a billion dollar. Many billion dollar industries probably should be a katrillion dollar industry if people understood that. It doesn't make you a bad partner. Most women are never gonna orgasm from penetration. Those who do, they're my ninja unicorns. They're extra sensitive. I have theories behind that if you're curious. But the reality is, is most people orgasm from clitoral stimulation just like most men orgasm from penis stimulation.
- [20:23]
Dr. Mary Claire Haver
That Hollywood, every woman has a earth shattering orgasm within 14 seconds of penis and vagina.
- [20:30]
Dr. Rachel Rubin
Why is the WWF not real? You know, it's entertainment. How are you go, how are you going to depict a female orgasm and female pleasure? Who's doing those depictions and how do they choose to do it? And then it's this thing of have they always done it that way? Because that's what normal or that's just how they've done it and they continue to do it that way is probably the answer. But it's wild, right? Because people think they come. No man comes to see me as a doctor, Ruben, I'm broken. I rub my thigh, but I just can't orgasm. You're like, well, no shit, that's not your penis. Right? So it's really, you know, when women say I'm broken, I can't orgasm from penetration. Well, probably going to take you longer than five and a half minutes to have an orgasm with a partner, which is what the data shows. Your partner certainly not lasting much longer than five and a half minutes, which is what the data shows. And so sex needs to become more than just about penetrative activities. Right. And it should be more than just about orgasm. It should be sort of adult playtime fun that people are having and they're laughing and they're joking and they're enjoying each other's bodies if that's fun for you. And then the question is, how can we make you drive better if that's what you want?
- [21:35]
Dr. Mary Claire Haver
You know, I think about the misunderstanding of this genital anatomy and where the clitoris is. How do you think this is playing out in like surgical mishaps and things that, that go wrong in the surgical space? Because we were never taught the really the correct anatomy.
- [21:51]
Dr. Rachel Rubin
Yeah, this is a true disaster. We. I would say I got some of my popularity back in 2022 when this brilliant woman, Rachel Gross, journalist who wrote this book called Vagina Obscura. It's a great book, but she wrote an article in the New York Times that was called Half has a Clitoris. Why don't doctors study it? And part of this article, everyone should go read it. It was the most shared article in 2022. And part of it was this idea of if you're having a hip replacement, if you're having a pelvic surgery, if you're having Something and your doctor was never taught about your clitoris. And no one's even studying whether or not that surgery has effects on your orgasm or your clitoris. Because the questions that we ask in research are not correct or really granular enough to pick up on changes. There are people being harmed by things like vulvar surgeries or pelvic surgeries or orthopedic sur. These patients are left with no options, and no one's even studying it or curious about it. Even the anatomical diagrams in our anatomy textbooks don't have the full extent of the clitoris, and they don't have the neuro innervation. So the nerves, which actually go around the uterus to the arousal nerves are going to go around the uterus and go to the clitoris. So all those hysterectomies, again, could be affecting arousal. Not just sensation of I feel the clitoris being touched, but I feel the engorgement. I feel the blood flow. The penis is innervated right by the pudendal nerves, which is the sensation. I feel my penis being touched. But then there's the cavernosal or, you know, arousal nerves that go through the prostate and allow that erection, that stretching of the. The erection. So it's the same anatomy, except the textbooks show the penis one, and no one even looks at. At. No one's even decided to study the clitoris side of things. And so we don't even have that data. Right.
- [23:35]
Dr. Mary Claire Haver
So a lot of patients, at least on my end, would complain of some change in their sexual function after hysterectomy. Now, some, it was positive because they had this big giant uterus that was driving them crazy and causing pain, and we've gotten rid of that and now they're happy. But like, some were like, whoa, something's really, really different. And I was taught that that was unless there was a surgical complication. This was psychological.
- [23:56]
Dr. Rachel Rubin
So it is not psychological. And it needs to be studied further. And what the data shows, listen, if you need a hysterectomy because you're bleeding like crazy, you have pain with a fibroid, you have endo. Like, if you are getting a surgery for a reason, you are usually pretty damn happy that that surgery happened. And so the data shows improvement in sexual function overall. But the data doesn't get granular enough to talk about arousal and orgasm, because we're barely asking women. Think all your listeners. Has a doctor ever asked you about your libido, arousal, orgasm or pain? Right. Maybe you've gone to the doctor to say, hey, I have a libido problem or a PA pain problem. But have doctors ever brought it up? Have they ever, before surgery, said, hey, this surgery could affect your libido, arousal, orgasm or pain, or hey, how do you orgasm? Because if you are one of those ninja unicorns who can orgasm from penetration, who like your cervix stimulated or you feel you have a uterine orgasm, which is what some of our patients describe. Will my surgery hurt that? I had a patient once, she came to say, she said, Dr. Rubin, I used to orgasm and I tasted color when I orgasm. So that sounds pretty good. She said, but I lost it when I had my hysterectomy and I want it back. Please can I have my. Can I have that orgasm back? And I was like, I don't know. Right? Because no one asked you before surgery, how do you experience pleasure? So I'm not saying don't take out the uterus if it's indicated and the patient needs a hysterectomy. I'm not saying don't do it. I'm saying ask your patient, you know, a little bit more information about how they experience pleasure in the bedroom. Because it matters. Because there are patients who really love anterior vaginal wall stimulation. There are patients who listen the smart. What did you learn in OBGYN residency about cervix inner innovation?
- [25:35]
Dr. Mary Claire Haver
Cervix has no nerves.
- [25:36]
Dr. Rachel Rubin
Okay? So everyone hears that, right? OBGYN Thai Academic center was taught cervix has no nerves. Yet when you stick the cervix and pinch it for an iud, does it not hurt people? They scream. So there are no nerves. That doesn't make sense.
- [25:48]
Dr. Mary Claire Haver
And you're like, after the X amount time, you're like this. This is hurting her.
- [25:54]
Dr. Rachel Rubin
And so the research shows that it's not only innervate. It's not only is it no nerves, it's triply innervated. There are very few organs that are innervated by three different places. So it's innervated by the pelvic nerve, the hypogastric nerve, and the vagus nerve, which is why you do that. And they kind of feel, you know, when you vagal, right? So which is.
- [26:14]
Dr. Mary Claire Haver
They get dizzy and nauseated and try to.
- [26:16]
Dr. Rachel Rubin
Which is also cool because this amazing researcher, Barry Kamazurak, he proved that even someone with a spinal cord injury, if you stimulate their cervix, can have an orgasm because of the vagus nerve. Which is just awesome research. But. But ob gyns are taught no nerves. The actual reality is it's triply innervated. So when women come in after hysterectomy and say, hey, my orgasm has changed, believe them, believe them. And let's show that curiosity of, well, wait a minute, maybe the science I was taught, maybe it's not true. And it's like, do we know the answer? Do we not know the answer? Have I just not been taught the answer?
- [26:51]
Dr. Mary Claire Haver
So you treat women who by the time they get to you, cause you're like high level specialist. Like a woman doesn't think I need to go to a urology.
- [26:58]
Dr. Rachel Rubin
Right.
- [26:58]
Dr. Mary Claire Haver
You know, most women don't even know that a sexual medicine specialist exists in the world. So it's probably safe to assume that women have been bounced around by several doctors. I see them pushed into anxiety and depression. Diagnoses based on this. Is this what you see as well?
- [27:17]
Dr. Rachel Rubin
Absolutely. So it, you know, the data is very clear. If you have pelvic pain specifically, right. You go to like 10 doctors, 15 doctors before you get to someone, it's getting better. The Internet is helping here and these patient advocacy groups are helping here. And I had a patient. This was, this was actually so magical. I had a patient come to see me. She was 16 years old. This is quite a few years ago. I think she graduated college at this point. And she said, Dr. Rubin, I need a specific vulvar surgery for pain. She said, I need a vestibulectomy. And I said, oh, nice to meet you, tell me more. And she said, I watched a show called Sex Education and in that show there was a character who had vulvar pain and she saw a doctor and she learned about X, Y and Z. So I went on Google and I looked this up and I found a doctor and I've examined myself and I think I might need a vestibulectomy. And I said, holy shit, am I excited for the future. Because we were, we did a whole history, we did a whole physical exam, we tried a few conservative therapies, but ultimately she actually did need that surgery. She was completely right. What was so cool about her case in her surgery is she didn't have all the mind drama of years and years and years of being dismissed. She didn't have the relationship. She was a swimmer who wanted to wear tampons. She wasn't having sex, she just wanted to wear tampons for swimming. And so once she had her surgery, it was like getting her appendix out. You're like, now I don't have an appendix. And she was able to wear tampons and she Was able to have.
- [28:35]
Dr. Mary Claire Haver
And couldn't wear tampons because of pain.
- [28:37]
Dr. Rachel Rubin
She couldn't wear tampons because of pain.
- [28:38]
Dr. Mary Claire Haver
Sorry. I'm sure someone's out there going, ding, ding, ding, Listening. Okay, what if. What is a vestibulectomy? Where is the vestibule?
- [28:46]
Dr. Rachel Rubin
Yes. So let's go back. So if. Okay, pain is not. You should never have pain.
- [28:50]
Dr. Mary Claire Haver
Okay, let's be clear. Say that louder for the people listening in the back. You should never have pain.
- [28:56]
Dr. Rachel Rubin
Yeah, it shouldn't hurt.
- [28:57]
Dr. Mary Claire Haver
Ever.
- [28:58]
Dr. Rachel Rubin
Yeah, it shouldn't hurt. Right. Section hurt. Penetration shouldn't hurt. Speculum shouldn't hurt. Tampon shouldn't hurt. Speculum shouldn't hurt. If there is pain, you must get a diagnosis of why you have pain. Okay, you must get a diagnosis. You couldn't. Should not get a diagnosis of you're stressed or, oh, the doctor, you know, you just need to relax or, oh, you just need time or you need to stretch things out. You need a diagnosis for why you have pain. And so there are often big reasons why you might have pain. Maybe you have a tissue problem, and we'll talk about that. You may have a muscle problem because your pelvis is just surrounded.
- [29:32]
Dr. Mary Claire Haver
Let's go there.
- [29:32]
Dr. Rachel Rubin
Let's go there.
- [29:33]
Dr. Mary Claire Haver
Why would a woman have pain in this area? It's such a small area.
- [29:38]
Dr. Rachel Rubin
So if you have superficial pain, so anything penetrating hurts you, it could be a tissue problem, like in the tissue called the vulvar vestibule, which is actually bladder urology tissue that nobody taught us. You could have a nerve problem. Right. So you could have a nerve issue, or you could have a muscle issue from your pelvic floor muscles. And so it is important to see a sex detective or someone who can look at your tissue to say, wait a minute, here's your story. Here's maybe there's a hormone issue that's causing an irritation of your tissue, like we see in menopause or birth control pills. We see changes in this tissue called the vulvar vestibule, which, again, is a strip of tissue that surrounds the urethra, which is the hole you pee through. So if you spread open those inner wings, those labia minora, it surrounds sort of the urethra, it's below the clitoris, and it goes all the way down to the opening of, you know, sort of all around. It's like a sort of a rim of a rim that can be of a fire. We call it the rim of fire. And so what's so fascinating and important about this tissue that none of us were taught in medical school is you understand that the outside of your cheek is different than the inside of your cheek, right? One is skin that's very, very thick. It's very protective. So if you took a jalapeno pepper and you rubbed it on the outside of your cheek would feel very different than if you rubbed it on the inside of your cheek. The inside of your cheek is mucosa, it's very delicate. So this volum, our vestibule tissue, right, the labia, our skin, it's tough, it's.
- [31:00]
Dr. Mary Claire Haver
It'S, it can, they can take a.
- [31:01]
Dr. Rachel Rubin
Beating, they can take a jalapeno pepper inside, inside the labia minora is where it turns into the inside of your cheek. And that is called the vulvar vestibule. And it's actually different than the vagina. It's so subtle. It is not a large piece area. But this is the rich biology that causes genitourinary syndrome of menopause or pain with tampons or pain with speculums. And this tissue is very hormone sensitive. It's rich in hormone receptors, both estrogen and testosterone. And so again, this is where the, you know, people like me are screaming from the rooftops about it because we see it all day, every day. Our colleagues are seeing it, but they miss it because they put the speculum in and it bypasses that tissue. And if you were never taught to look for something, you're never going to find it. Right? And most doctors are not routinely taught how to examine this tissue. So that's why my colleagues and are yelling from the rooftops of hey, here's a Q tip. This is how to examine the tissue. We've made videos, we've published in the Video Journal of Sexual Medicine.
- [32:01]
Dr. Mary Claire Haver
Where would you find those videos?
- [32:03]
Dr. Rachel Rubin
Video Journal of Sexual Medicine has some amazing videos and we're getting more and more. We've got videos on how to examine a clitoris, on how to examine a vestibule, on how to work up things like. And our team is, you know, all of our colleagues are working on more and more videos because the more we can get it out there, you know, sort of the better things will go. And so this tissue is, it can be a source of pain for many people. Hormones affect more than, than how you feel. They affect your skin too. As estrogen drops in midlife, your skin can lose collagen, hydration and elasticity. That's where Alloy Health comes in. Alloy makes evidence based menopause care accessible. Connecting women with menopause experts and now they're redefining skin care with M4, their prescription line made with Estriol, a form of estrogen that only works on the skin. It started with the M4 Face Cream RX and now Alloys added two game changers, the M4 Face Serum RX and the M4 Eye Cream RX. Getting started is easy. Head to myalloy.com that's my a l l o y.com answer a few quick questions and a licensed physician will review your info. Use code MCH20 that's MCH20 for 20 bucks off your first order, your personalized skincare ships right to your door. No appointments, no pharmacy lines because your skin's changed, changing and your routine should too. Visit myalloy.com and use code MCH20. That's MCH20. Eczema is unpredictable, but you can flare less with Epglis, a once monthly treatment for moderate to severe eczema. After an initial four month or longer dosing phase, about 4 in 10 people taking EBGLIS achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing. MGLIS Lebrekizumab LBKZ, a 250mg per 2ml injection, is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema, also called atopic dermatitis, that is not well controlled with prescription therapies used on the skin or topicals, or who cannot use topical therapies. Epglis can be used with or without topical corticosteroids. Don't use if you're allergic to Ebglis. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with Ebglis. Before starting Ebglis, tell your doctor if you have a parasitic infection. Ask your doctor about ebgliss and visit ebgliss.lily.com or call 1-800-lilyrx or 1-800-545-5979.
- [34:30]
Dr. Mary Claire Haver
Okay, so you have skin issues so that cause pain. And you mentioned muscle.
- [34:35]
Dr. Rachel Rubin
Yep.
- [34:35]
Dr. Mary Claire Haver
So what is that like?
- [34:36]
Dr. Rachel Rubin
So your pelvis, everybody's pelvis. If you have a pelvis, it is bones that are surrounded by very thick, big muscles and these muscles are so important. They're called the pelvic floor muscles. And they help so you don't, you know, fart in public, right? They help so you can hold your urine. They help release the urine. They help relax enough to have sex. They help, you know, they contract delightfully when you have an orgasm, right? They like these muscles. And there are superficial ones and they're deeper ones, and they're very big muscles. And I don't know about you, but when I'm working all day at a computer, like, I get sore muscles sort of in my neck. That's where I get, you know, my muscles tighten up. Well, listen, I work in Washington, D.C. we're full of a lot of tight asses in Washington, D.C. but what can happen is you can feel those muscles in your pelvis sort of tighten up, right? And so what can happen is people can hold their stress or there can be problems or things like endometriosis or, you know, problems that can tighten these muscles. And so they come with symptoms. You can have urinary frequency, urinary urgency. You can have difficulty having bowel movements. You can have pain with intercourse. You can have difficulty with any kind of speculum or tampon. And so this is where we work with our. We get a good diagnosis, and we work with our musculoskeletal colleagues, the geniuses of the world, who we call pelvic floor physical therapists. And if you have, like, they. They treat men, they treat women, they treat every. You know, and they. They relax and get these muscles rehabbed because you can get a knee replacement and rehab makes sense to you. But if you have a watermelon come out of your vagina and you have a baby, rehab suddenly doesn't make sense to you. And that's kind of wild.
- [36:14]
Dr. Mary Claire Haver
Amazing. What are the, like, common misdiagnoses that you see after women finally make their way to your office?
- [36:21]
Dr. Rachel Rubin
I didn't realize how I love my job so much. It's just insane how much I love what I do. And it is because I always say to patients, like, I am not a magician. I truly am not a magician, but my batting average is really good. Because when you spend time with someone and you get to know them and you figure out what they care about, you can optimize and help, like, reach their goals and give them a toolbox that then choose from to kind of get better. And it's when you do that that we see really, truly magic happen. And I didn't realize how much sitting with people and listening to them and then using biology to help them explain their symptoms in A biopsychosocial way and using what I know about science and anatomy and physiology to help be like, well, this makes sense because this is what I know. And let me show you pictures and let me show you diagrams and let me teach you what I know. I didn't realize how that was medicine. I had a patient just this week where she had seen so many doctors. So doctors. And she thought that I was just going to be another doctor that didn't have a hypothesis, didn't have an idea, and just told her it was all in her head. And I gave her a mirror, which we do in our field. We give people mirrors and we say, this is your labia majora. This is your labia minora. This is your clitoris. This is your vulvar vestibule. This is your pelvic floor. And you poke them and you find their pain, and you find where they don't have pain. And they've already looked at diagrams, so they are. They are just as smart as you at that point. They see their pain. They see it in the mirror, and when you touch it and you say, does that hurt? And they say, yes, that's what it feels like. That's what sex feels like. That's what my UTIs feel like, the tissue where it hurts. You see their brains, their eyes, their bodies just sort of all of a sudden believe themselves. That is the most incredible thing. They just believe themselves because they've been gaslighting themselves. They've been gaslighting themselves of like, well, surely this is in my head, because I've seen 10 doctors, and that's the magic, right?
- [38:04]
Dr. Mary Claire Haver
Have they been told that everything looks.
- [38:06]
Dr. Rachel Rubin
Normal all the time? In fact, I had a patient recently who had a vestibule pain, and she had been to vestibule doctors and pelvic floor physical therapists, and nobody could. She said, no one ever finds my pain on exam. She says, you're never going to find my pain on exam. And I said, oh, my gosh. Okay, let's look and let's do it. And I found her pain on exam. And she looked at me like I was some kind of wizard, right? And. And she didn't even believe it. She had the mirror and she's like, oh, my God, you're going to believe me. You're going to be the first one to believe me. I said, of course I believe you. Your story makes perfect sense. Your exam makes perfect sense with what's going on with you. Again, I joke that I'm a sex detective, right? This idea of like, I hear a story and then you come up with a hypothetical. Then you start think. You're thinking, is this in your brain? Is this in your spine? Is this in your pelvis? Is it your nerves? Is it your muscles? Is it your tissue? And I, because I'm so curious about this, which is funny because I think of myself as not a curious person sometimes my thoughts and my realities are not always the same. But I think to myself of like, of like, can the biology make sense here? And I'm curious. And then because of social media, I've always been friends and I am able to think of things like endometriosis. I'm not an endometriosis specialist and I diagnose endometriosis all the time because I examine people, I hear their stories. And I was like, you need to go see someone who does this because I'm pretty sure you have endometriosis. Or we see so many people with connective tissue problems. Things like. And you must do an episode on connective tissue and Ehlers Danlos and mast cell problems because it is an epidemic that nobody is looking at and nobody is seeing. But we see these people who have these whole body allergy like symptoms and they're always hurting themselves and their guts are a mess and their pelvises are a mess. And it's like, wait a minute, this is not just a pelvis problem. This is a whole body problem or menopause. Right? You see whole. They come to me for a urinary problem or a pelvic problem. And I'm like, no, this is perimenopause in your whole body is being affected. And we need to look at all of you and treat the problem that you came in with.
- [40:02]
Dr. Mary Claire Haver
So let's, let's move on to genital urinary syndrome of low estrogen. Right. I hate calling it of menopause, but there were, there is a menopausal version because there are multiple times in a woman's life she might have low estrogen that is going to give her pelvic symptoms.
- [40:18]
Dr. Rachel Rubin
And I would clarify. And this is actually the problem. So the name of this condition was used to be terrible. Well, atopic vagina. Well, even telling you senile vagina was my favorite. Right. There was a paper long ago, Xenophon vagina, which then became atrophic vaginitis, which is not very nice, or vulvovaginal vagin. It's horrible, horrible names. And so in 2014, a bunch of our colleagues got together and said, this name is Terrible. And it was one urologist in the room, my mentor, Erwin Goldstein, who said, wait a minute, the word urinary must be in this name. And they called it genitourinary syndrome of menopause. And those are the signs and symptoms that happened with a low hormonal state. So it's not just vaginal dryness, which is what everyone thought of it as, but it's actually change in arousal and orgasm. It is dryness, it is decreased lubrication, it is pain with intercourse, but it's actually a very serious urologic condition which causes urinary frequency, urinary urgency, leakage, and urinary tract infections, which can and do kill our patients.
- [41:17]
Dr. Mary Claire Haver
Right, so let's break it down. How does low estrogen states cause the urinary symptoms?
- [41:25]
Dr. Rachel Rubin
Yeah. And one clarification is it's not just estrogen. And the guidelines that we put together, the American Urologic association association, is so historic because the word androgen is all over that guideline. Because actually it's just a low hormone state. Right. And that's a challenge because women are told all the time by their OB GYNs, because those are the only people talking to these women. Right. And they say, well, you're normal if your periods are normal. Well, you're normal. You're not having a hormone problem if your periods are normal. And we have to stop telling women that because it's not true.
- [41:54]
Dr. Mary Claire Haver
That is controversial. I mean, when you look at the way that we diagnose perimenopause, if it's even on your radar, it is bicycle irregularity. And I have a huge problem with that.
- [42:02]
Dr. Rachel Rubin
But again, it's not a. About menopause. It's about androgens dropping in your 30s. And so we. The genital tissue is androgen and estrogen driven. And so what's happening?
- [42:12]
Dr. Mary Claire Haver
So by androgens for our listeners, you. You're Testosterone.
- [42:15]
Dr. Rachel Rubin
Testosterone, Right. So testosterone changes. And actually, the menopause people are very clear that this isn't a menopause problem. It's an age problem. So in your 30s. If you're listening and you're in your 30s and you're saying, oh, I keep getting UTIs, I keep getting vaginal infections. I keep. Oh, BV keeps coming up. Oh, I keep. Sex kind of hurts now. I need to, you know, I just don't like it as much or early in my period. It just, like, doesn't feel so good. I'm a little irritated. Right. What's happening? Or my libido is a little Bit lower, your testosterone is dropping precipitously. Okay. And that causes genital and urinary changes. Sometimes they can cause mood changes or libido changes. Now, we don't study it to the level that we should. Again, going back to, we need more funding, we need more research in women's health. But if you feel not like yourself, it's real. I'm gonna say it. It's real. Right? And that doesn't mean science is fully figured out with guidelines to give you a book answer. And every doctor is going to give you the same answer, but it doesn't make it any less real. And so when these genital and urinary symptoms are happening, it's because of hormone changes. And so the terminology genitourinary syndrome of menopause is a little bit not good because it's not menopause, it's perimenopause, it's breastfeeding, it's, it's postpartum, postpartum. It's birth control pills can cause these hormonal changes. Even though birth control is hormones, it's adding back fake estrogen and fake progestin, but it's not adding back testosterone. And so we do see women who, on many women on birth control do great. But there is a subset who start having pain with tampons, pain with sex, vaginal infections, urinary tract infections. And our guidelines that we wrote were very clear to include these patients, to say we should be giving these people vaginal hormones, either vaginal estrogen or vaginal dhea, which are all FDA approved and should be used in more than just the menopause population.
- [44:04]
Dr. Mary Claire Haver
So in gsm, we have urinary symptoms. You mentioned arousal and orgasm. So talk about those in this low estrogen, low hormone state.
- [44:13]
Dr. Rachel Rubin
So hormones are like water to a plant for the genitals, right? So baby genitals, babies don't have any hormones in their body and their genitals don't look like grown up genitals. So babies have no hormones. Then they become jerky teenagers and their, their genitals literally blossom, right? You grow labia, they get bigger, clitoris grows, you get an opening that is not red and irritated, but it's lubricated, it's pink, it can put tampons in, it can have sex, it can make babies, right? The genitals transform. And that is because of a surge of hormones, estrogen and testosterone. And so with that surge of hormones, the genitals change. So it makes perfect logical sense that when you then lose hormones and we we turn off the cycle, which happens in perimenopause and menopause. Then the genitals are going to change because they're very responsive to hormones. So I, you and I broke the Internet this year because we like in.
- [45:04]
Dr. Mary Claire Haver
Reference to that viral video where you talked about the loss of the labia.
- [45:09]
Dr. Rachel Rubin
Okay, yeah. So it is fact. I'm going to say this out loud for the whole world to hear. It is a fact that when you lose hormones, the labia minora start to resorb. That means they start to shrivel up and go away. That doesn't mean everyone loses their complete labia. For all of you saying I should lose my medical license, it means that the labia minora changes. They do change and they do. If you open your eyeballs, you're going to see the labia minora change in menopause. We actually don't know from science. Is it estrogen? Is it testosterone? Is it something else? I want to study this. This is my dream, to have a lab where we can study these very important questions. But it changes. And, but it's not just the labia that change. The clitoris gets smaller.
- [45:47]
Dr. Mary Claire Haver
Talk about that. The clitoris, the volume of the clitoris.
- [45:50]
Dr. Rachel Rubin
The clitoris is a testosterone driven organ, right? If men lose testosterone, their penis shrinks up. If women lose testosterone, which they do in their 30s, their clitoris starts to get smaller. If you use things like birth control, it's probably, it may affect the size of your clitoris, but we haven't studied it to the level that we should because we don't study women's sexual health. Right. It's, it's so, it's this wild thing again. So you. Arousal, right? Again. Plant needing water in order for the vagina to arouse and to fill with blood and to. And to. You need hormones to help with those with arousal and lubrication. The tissue requires hormones in order to work well and have a healthy microbiome and a healthy environment. And so when you lose hormones, there are consequences. And those are the sexual symptoms which historically everyone said, just use some lube, lady. And I'm sorry, We researched this for the guidelines. Lubricant makes painful sex go from 8 out of 10 pain to 4 out of 10 pain. I don't know about you, but I don't want to have sex if I have 4 out of 10 pain. Every time I try to have sex. Even if it's a little slippery or. Right. So what if we made the pain go to zero and then added some lubricant that sounds like it's a better option to me, right? And it's safe. And that's the challenge.
- [47:03]
Dr. Mary Claire Haver
You know, the old guideline said you don't start, you don't replace the hormones or consider hormone treatment until they failed. Lubricants.
- [47:12]
Dr. Rachel Rubin
It was my personal mission in life. My biggest goal in life was to do what we did this year was to shut down, that being the rule, right? The first line therapy is moisturizers and lubricants. Because moisturizers, lubricants do not prevent urinary tract infections. Urinary tract infections kill your urinary grandmother. They kill your mother, they kill the people that you love. And we should be preventing them with every fiber of our beings.
- [47:35]
Dr. Mary Claire Haver
And how much can we prevent with. With vaginal estrogen?
- [47:38]
Dr. Rachel Rubin
More than half. More than half. And it's probably higher than that, but the data is. Is more than half. In, in most studies.
- [47:44]
Dr. Mary Claire Haver
It's every ICU doctor, every ICU nurse is going crazy right now because they are constantly chasing my mother in the nursing home. They are chasing UTIs, neurosepsis.
- [47:55]
Dr. Rachel Rubin
I'm so excited to do this, right, because every nurs. Is. Is. Has a huge problem with urinary tract infections. Because when little old ladies get urinary tract infections, they get delirious, they get, they break. They break their hips. It is costing our healthcare system so much money. So we published this year, or not this year, in 2024, if we gave women in Medicare vaginal estrogen, just prophylactically is so safe. Is. There's literally not a paper on earth that shows harm. If we gave women vaginal estrogen, we could save Medicare between 6 and $22 billion a year. And I, I think it's a conservative estimate, which is insane, right? And so it should be talked about. But I always joke and, and I wish this. It's kind of serious, right? There's two dirty words in the English language, vagina and estrogen, right? Everyone has so many feelings about the word estrogen, and the word vagina can barely get talked about at all. So your ICU doctor, the last thing they're going to want to talk about is vaginal estrogen. And so we actually need a rebrand. Like, I think we should call it like GLP 12 or something. Like call it a peptide, like this LP peptide. It's a little insert you put. You know, you just place it vaginally. But it, it's your bladder microbiome support. It's your, it's your probiotic it's your essential oil. Call it whatever you want, it literally will save lives. And yet no one is getting this information. And so you on your podcast talk a lot about whole body hormone therapy. And I love whole body hormone therapy. So estrogen, progesterone, testosterone. But what every woman can and should consider and should use is local vaginal hormones which are low dose, they don't travel throughout your whole, they're safe for great grandma and they prevent urinary tract infections. And so yes, there are sexual benefits. Like I talk all the time how they're Viagra, right, like you. And they increase blood flow. They increase blood flow, they help with arousal, they're better than Viagra, they help with urinary symptoms because they prevent urinary tract infections. And so whether it is a tablet you put in your vagina, 10 microgram estradiol tablet twice a week. So for all you ICU doctors listening, estradiol, 10 micrograms twice a week in the vagina till death does she part. Or a estrogen cream, which tends to be the cheapest option, cash price, a 0.01% estradiol cream, 1 gram twice a week, rub it into the walls of the vagina till death does she part. These are not hard prescriptions to write. And so on our website we have a free provider's guide of how to write the prescription. I have free trainings all on my website of how to treat genitourinary syndrome of menopause are guidelines that the American Urologic association put out. It is a step by step handbook of how to do this as easily as possible because our primary care of friends. I need you to do this. I need you to get your hands, roll up your sleeves, write the prescriptions and, and you will save lives.
- [50:37]
Dr. Mary Claire Haver
Talk to me about DHEA and the differences, you know, how is that different? And the vaginal dhea and would you consider systemic dhea?
- [50:44]
Dr. Rachel Rubin
Yeah. So from what I understand, the systemic DHEA data is kind of all over the place. It's meh. And so when you take a pill of dhea, I don't have a lot of data to say you definitely should do this for your health because it.
- [50:54]
Dr. Mary Claire Haver
Is the darling of, of the wellness.
- [50:57]
Dr. Rachel Rubin
And I'm not here to just like, I, I think, I'm not saying it's like, I think I would love to see more data and more research on it. You know, again, your adrenals make lots of DHEA and, and so but when you put it vaginally and there is an FDA approved product of vaginal DHEA. When placed vaginally, it helps with preventing UTIs. We published on that. It helps with pain, with sex. It helps with all of the same microbiome issues that vaginal estrogen. And it may be useful in your patients on aromatase inhibitors and things like that where it blocks, right, the arom inhibitors is blocking the estrogen, but you can still get the androgen benefit from the dhea. And that needs to be further studied as well. And so dhea, remember the vagina, the vestibule, the clitoris, the bladder has estrogen and testosterone receptors. DHEA is the precursor to estrogen and testosterone. So it makes logical sense. I love logic. When I don't have data, I use logic. Shocking. It makes logical sense that it is a good option for this tissue, especially if estrogen is not doing enough. We've seen some urgency data where your urinary urgency, if you're still having on vaginal estrogen, you switch to DHEA and you can actually improve some of that urgency. The challenge is getting it covered. So for all you insurance companies listening, it's getting it covered. We just fought really, really hard to get it covered. First line for the veterans administration and it was. So we've just worked to get it on formulary for veterans, which I'm very proud of. I fight like, like hell in that organization to get these products sort of approved for veterans.
- [52:24]
Dr. Mary Claire Haver
A lot of pushback in our older patients who aren't comfortable touching their vaginas, who, who you know, and especially nursing these nursing homes, a lot of these women can't do it on their own. My mother certainly can't do it. And it's like finding the staff to do it. Where does ospinoffine would you think that this.
- [52:41]
Dr. Rachel Rubin
Yeah, so it's a great point, right, because people are really hesitant because again, vaginas come with a lot of feelings and a lot of dirty words and a lot of emotional connection. And it's a very challenge. But like if the best way to give it is vaginally, it's kind of figuring that part out. So can they do a little insert suppository? Because locally see seems to be the best. I hope companies listening and I know there are some developing different products that may be able to be better options, you know, for our elderly or nursing home populations. Ospeniphene is an FDA approved product. That's a pill you take by mouth that helps with the genitourinary syndrome of menopause. I think it needs to be studied in the older populations because my concern is when you do a systemic whole body product, and this is a cirm, an estrogen receptor modulator, I think you do increase, increase the worry is that you increase your risk for something like a blood clot. And so putting a woman who's 90 in the nursing home, whose memory problems on an oral pill that could go through the liver and increase the risk of blood clot, then your risk benefit discussion might change a little bit. So, but yes, it would be lovely to have a pill that could help a vaginal pro, you know, a vaginal bladder problem and not cause any side effects.
- [53:50]
Dr. Mary Claire Haver
So speaking of side effects, we'll go back to. You casually mentioned SSRIs and antidepressants. I remember looking at the data on when HRT prescriptions hit the tank. So before the whi, the Women's Health Initiative, which we've discussed on this podcast ad nauseam. But in case you've lived under a rock, after this data was released from the Women's Health Initiative, about, we guess 30 to 40% of women were on some form of systemic HRT and that dropped to almost nothing. So as of two years ago, FDA approved formulation were at about 4%. But what we did see was sleeping pills and antidepressant prescriptions skyrocketed after. So right now a woman has about a 10% chance of being on an SSRI, an antidepressant, before what would be perimenopause. It doubles across the menopause transition and then goes up again at 65. A lot of that. I think while we see that like dramatic increase of the mental health changes we see at perimenopause, Doctors aren't trained in menopausal medicine. They don't what to do. They're going to treat the symptoms, throw an SSRI at them. But there are sexual side effects as well. Yeah.
- [54:56]
Dr. Rachel Rubin
And it's funny because no one seems to disagree that there are sexual side effects of antidepressant.
- [55:01]
Dr. Mary Claire Haver
There are sexual side effects.
- [55:03]
Dr. Rachel Rubin
And so patients understand this, doctors understand this. This idea of if you take an ssri, certain ones are worse than others, that you may prolong orgasm. Right. It may take a longer to have an orgasm or not at all. Right. We have people who can't orgasm.
- [55:16]
Dr. Mary Claire Haver
All we were taught was sexual side effects. We did not quantify.
- [55:19]
Dr. Rachel Rubin
Okay, well, let me quantify it. Okay, fine. So, yeah, so and so. So okay, medicine can have sexual side effects. It, it right. It just. That's the way that it works. And so antidepressants can have sexual side Effects, we see a lot of low libido, we see a lot of delayed orgasm. And so if it matters to you, then it should matter. And we should have a tool, tools in our toolbox to help with this problem. And the challenge is, is anti. If you're depressed, it also has sexual side effects. Anxiety has horrible sexual side effects. And so it's that balance between treating your mental health, supporting you, working with a team to figure out what do you, the person need and what side effects are acceptable and what medicines can we use to limit the bad side the, the bad side effects and promote the good effects. Right. It becomes working to figure out with your doctor of what matters to you. Right. If you take an antidepressant and it's changed your orgasm and that upsets you, then you have every right to go to your doctor and say, I miss my orgasm. Is there something else I could take or is there something I, I could add? And, and how do we sort of quantify this? And this affects both genders significantly. And one, there was a recent New York Times article that really went into, you know, giving all these drugs to kids and teenagers is how are we having those informed consent discussions with them when we never talk to kids about sex at all? And I think they did a really good job of painting the complexity of the issue because we're not saying don't medicate someone who is in deep need of mental health support. But it becomes how do we talk about and research and look at the sexual side effects which are, you know, can also genital numbness or, you know.
- [56:51]
Dr. Mary Claire Haver
Because it's, there's a libido issue potentially, and then there's also arousal and orgasm issue. So let's break those down because the.
- [56:58]
Dr. Rachel Rubin
Listeners are like, whoa, yeah, no. And, and, and there are some that really don't get talked about. So there's. So again, sometimes low libido can be seen, sometimes change in orgasm can happen. Sometimes change in arousal can happen so that either the erections or clitoral arousal. And we see the, we see these different conditions, you know, genital, what we call dysesthesia, or when your genitals just don't feel like they used to. So patients report it's, it's really, it's wild because patients will say, I feel like I feel nothing when my genitals get touched. Like I feel the sensation like you're touching me, but it's no different than if you touched my elbow. There is no longer that sexual sensation. And you have to be very careful when you're listening to patients talk about sexual function because. Because sex education is really bad. And this country that we often don't have the same language. So I have a guy who comes to see me. He says, Dr. Ruben, I'm so mad and distressed and angry because my libido is gone. And when you really talk to him at length and you ask more questions, it's not just his desire or his interest in sex. It's sort of his arousal. It's his connection to arousal. It's his, you know, erections and things like that. And so you have to talk to patients, and that's with men, it's hard. With women, it's damn near impossible because women are not taught anything about, you know, sort of the language. They don't have the language. And so you have to teach them their bodies, their anatomy to even find out sort of where the problems might be. And so medications can cause sexual side effects. Okay, Mental health issues can cause sexual side effects. Bad relationships can cause sexual side effects. A partnerectomy, I always say, can be sometimes a really good cure for your sexual health. I love. I don't prescribe it often. I want to prescribe it often, but we just kind of cut your partner out of. Out of the situation. But it is biopsychosocial and, and I think too often we jump to the. It's all in your head sort of. Because it's easy. It's easy to tell people that and say, well, it's not my problem. Go see. Go see a mental health specialist.
- [58:55]
Dr. Mary Claire Haver
Why is sexual side effect counseling? Why do you think this is routine in men? I think because you get fired as a clinician and almost non existent in women.
- [59:05]
Dr. Rachel Rubin
It's a great question. So again, let's go back to this. You're ob gyn, who's responsible for delivering babies all night long. Emergency surgeries, massive blood transfusions, women dying in childbirth, dead babies. Like, they are responsible for the most horrific and insane things that you've ever seen in your life. And then every 10 minutes they're having to see someone else. So think about going to a room being like, you have a dead baby. Let's talk about it. And then the next room being like, oh, your libido's low. Let's talk about it. Like, that is not an easy life or job. There is a whole field of medicine devoted to the male penis, right? It is called urology. I am a urologist. I was taught, you know, the male penis is important. Erections are important, arousal is important. Viagra is a billion dollar industry. If you haven't watched the series on Viagra, it's fascinating because it's all about the marketing, is the biggest marketing campaign in the history of the universe. So you have a whole field of medicine devoted to the male penis. Yes, we do prostates and bladders and kidneys. But that's kind of, you know, that's sidebar. And the clitoris isn't even discussed in ob gyn sort of training. So you all.
- [60:06]
Dr. Mary Claire Haver
We know that there's one.
- [60:07]
Dr. Rachel Rubin
So yeah, we kind of know.
- [60:08]
Dr. Mary Claire Haver
We know that top part.
- [60:09]
Dr. Rachel Rubin
But if you look at creog, which is sort of your check marks of what I must know to graduate as.
- [60:14]
Dr. Mary Claire Haver
A resident, I was a former program director. I was in charge of the creog guidelines to make sure that we were covering all the lectures to hit all of the points. And the clitoris was not a part of.
- [60:24]
Dr. Rachel Rubin
What I understand and what I've heard is the word clitoris does not appear on any of those, you know, sort of segments. And so you have to understand. So it just isn't in the routine discussions of, you know, what women have with their doctors. And yet with, because of Viagra, because of sexual medicine in men, because of the pioneering research and work that people have done in this space, it has become just bread and butter, our urology. Right? But it doesn't just happen. It happens because people made it happen, because researchers made it happen, because money made it happen, because Pfizer made it happen. Right.
- [60:57]
Dr. Mary Claire Haver
They saw an economic opportunity.
- [60:59]
Dr. Rachel Rubin
That's why it happened. And so when we dismiss women, when we say it is all, you know, again, we have incredible, incredible psychosocial research for women about sex therapy, about mindfulness, about cognitive behavioral therapy, because there are strong, powerful women in those fields that, that do the research. So then we think it's all psychosocial, but it's not. It's just that the people being the loudest and doing the work are the psychosocial researchers. And so we don't mentor and fund and support women doing sexual medicine research. Because if you want to be taken seriously as a woman, you study prostate cancer, you study breast cancer, you study bone health, you don't study the clitoris. Right? We are the laughingstock of the medical community. And yet when you're old, orgasm breaks down. Who do you go see? Who takes care of you? Who. Who can you even talk to about it?
- [61:49]
Dr. Mary Claire Haver
So one other drug I want to cover as far as sexual side effects, and this we, you know, I feel like we have to Tread lightly, because this is like a hot topic political anytime we mentioned birth control and we talk about proper counseling and shared decision making and side effects, a lot of people get really upset because there seems to be a certain political group that wants to remove all access to contraception. That is not what we're talking about here. So I just want to be clear. These are medications and that have side effects. Walk me through. Because I've had. This has happened to patients that I didn't know how to help her, that of some of the sexual side effects of being on oral hormonal contraception, where we're, we're, we're seques. We're suppressing ovulation.
- [62:26]
Dr. Rachel Rubin
Yeah. So the data is mixed here, I would say, and I would love to see more data on it. But this. Let's think of how birth control works. Okay, Birth control, different kinds of birth control. But if you take an oral contraceptive, that is combined estrogen progestin, the goal of it is to treat, turn off your ovaries, which is elegant, right?
- [62:46]
Dr. Mary Claire Haver
So you don't ovulate, you don't ovulate.
- [62:47]
Dr. Rachel Rubin
You don't have a baby, and there's no fluctuations of your hormones. So in many ways it's very elegant and quite lovely. The challenge becomes when you are giving back this large dose of ethyne estradiol, which is. And a progestin that comes with side effects for some people, weight changes, mood changes, potentially other changes. Like any drug, there can be side effects, which is totally, again, reasonable for any drug to have side effects. Pros and cons. But what it doesn't do, like the ovary, the way I was taught, does estrogen, progesterone and testosterone. And so there's no conversation about testosterone. And so if we believe as a society that testosterone, that women have testosterone, it will make testosterone. And we know that testosterone helps with libido. Well, then if women take birth control and are complaining about low libido, which I know a lot of you listening are complaining about, is the logical answer that it may be a testosterone problem. It makes logical sense, Right? Do we have all the funding in the world and all the research to prove it? No. But for all the people listening, we would love to fund some research on this, but it may be a testosterone story. Now, again, I said that vulvar vestibule, where people have pain with sex at that opening around the urethra, has testosterone receptors. So researchers have seen that when women take birth control pills, that tissue can get red, it can get irritated, it can get painful. And when you examine it, you find a source of pain. And so women have pain with tampons and they have pain with sex, said, oh, I was fine until I started my birth control pill. And then everything went south. And so for those patients, we get their story, we talk to them, we examine them and we say, huh, could this be your birth control pill? Could we switch to something like a Mirena iud, A hormonal iud, which actually is not a combined, doesn't shut ovulation off so you still can make your own hormones. And we find that is a lot better for, for a contraception for these patients who are prone. And not every patient takes birth control has these side effects, but who do, they may have improvement. Now we also add back some local hormones, whether it's vaginal DHEA or topical estrogen. Or a topical estrogen, testosterone that gets compounded, Right. Those are treatments that we have seen work for these patients. And pelvic floor physical therapy, which all of those combined can be life changing. Not to say that also sex therapy also is wonderful because if something hurts you all the time, why would you ever want to do it? And you got to work on, you know that those aspects as well. So birth control, it has side effects like any other medication. And we should not dismiss those patients who say they have side effects. And we should be counseling women just like before they have surgery. We should find out do they have pleasure in certain areas. We should be asking patients about sexual health when it comes to their birth control choices. Because informed consent is, and shared decision making is the right way to do things. Right. And so what I find patients get most upset about is, well, no one told me that was going to happen to me. I didn't know what to expect.
- [65:44]
Dr. Mary Claire Haver
This could be a possibility.
- [65:44]
Dr. Rachel Rubin
I didn't even know that my birth control was the, the reason why I had pain with sex. And when you give them that information, some of them stay on birth control, some of them switch to an iud, some of them have like, like they have options, but they feel in control of those options. And again, that is medicine. When a patient knows what's going to happen and they can say, you know what? I heard all the options. I've weighed my pros and cons. This is what I would like to do. Right? And again, if you're thinking medico legally, like, like, I think those patients sue less because they feel like they were informed and a part of the decision making process, right?
- [66:17]
Dr. Mary Claire Haver
Oh, spironolactone, let's Go back for a second. Another medication was surprising, very commonly given for acne, for hair loss. You know, how does it work and why would it change?
- [66:28]
Dr. Rachel Rubin
So when I teach, you know, I would say when you play with hormones there are consequences, sometimes good, sometimes bad. So if it's good for your hair, it's probably bad for your genitals. And so that's like my go to, right? If it's, if it's a hair loss medication, it's probably bad for your sex life. I don't know why God made it that way, but it tends to be true. But so if it blocks testosterone, it might be good for your skin, it might be good for your, your hair. But again, you need testosterone and hormones for the oils of your body, for the lubrication of your vagina, right? Accutane dries everything out. So it's going to dry out your vagina and may cause pain and changes with arousal and orgasm. A finasteride for men can cause horrible sexual side effects in a certain population that we don't know which it will be and no one seems to study it to the level that it needs to be studied. We see again, spironolactone is one I think patients who exercise too much and don't get periods, right, they're having hormone change, depression. The, the patients with disordered eating are having hormone changes and problems. And so we have to understand that medications of all kinds, even supplements, right? If you're, you know, saw palmetto is one of the, in men that we can see that can lower testosterone levels. And so people are taking these supplements to try to help with hair which again, if that's your priority and you're okay with any side effects that you have, you do you like. I'm not here to tell you not to do something. I'm here to tell you that this is a possible explanation and something we could potentially try.
- [67:49]
Dr. Mary Claire Haver
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- [70:56]
Dr. Rachel Rubin
So one more.
- [70:56]
Dr. Mary Claire Haver
Drug in a new paper just has just come out or is coming out. I think I got a sneak peek of it is a paper looking at GLP1 use and sexual function. Did you read it?
- [71:06]
Dr. Rachel Rubin
So I think that paper is a hypothesis of what could be happening. I don't know if they have, if there's data, but we actually did a big survey and you helped us. Thank you. Because we put it out on social media and we did a big survey of GLP1 users. We've presented at a few conferences and we're working on the data now. But you do see about, you know, 10 to 15% sexual side effects with GLP1s. So my men are coming in saying they have delayed orgasm, lower libido. I've got women coming in. Some are saying I'm having better sexual function because I've never felt better in my body. And this is great. But I actually get just as many patients coming in saying I've never felt as good in my body, I feel great, and I have no interest in sex whatsoever. And so we are seeing sexual side effects from these medications. Again, that is not to say don't take them, it is to say that these, these are just like slow gastric emptying or nausea or side effects. Sexual side effects may be happening. And if I have patients who couldn't care less about sexual side effects and I have patients who their identity is their sexual health and those are different patients and we should treat them differently, I have patients who will literally travel to the ends of the earth to figure out what is going on with their sexual health because it's so important to them and, and I'm thrilled that they exist in this world and they're different patients and we are. So there are medications. So if we all agree now, we just had a huge convers that medications can cause sexual side effects. So let's use logic friends. Can medications boost sexual function? Of course they can. And of course we actually do have options. And here's a place where I have options more for my women patients than I do for my male patients. You don't hear that very often. Okay, we have two FDA approved drugs for low libido and premenopausal women. Okay. They work great in postmenopausal women and we use them frequently. And the data is very clear. They work in postmenopausal women.
- [72:51]
Dr. Mary Claire Haver
Yeah, I think that paper's coming out soon.
- [72:52]
Dr. Rachel Rubin
So the two medications is. The first one is Addie that came to the market and there is an amazing documentary, the Little Pink Pill film, that talks about the whole saga of how hard it was to get a drug for female sexual dysfunction approved in the fda. And if you've never heard about it, it is because that's how much we hate Talking about women's sexual health and we minimize the need.
- [73:14]
Dr. Mary Claire Haver
So for our listeners, if they don't know, let's talk about getting Viagra through the FDA versus getting Addi through the fda.
- [73:22]
Dr. Rachel Rubin
There's two drugs for FDA approved for low libido. So Addi and Flaban, Sor Fatty, which is flubanserin, and Vylisi which is Brimalinotide. One is a pill you take every day. Works like kind of like an. It works on your brain, so it boosts dopamine in your brain. You take it every night, similar to Wellbutrin, but the side effects are better. It kind of gives you a good night's sleep and patients really like it. And so it takes about, you know, two to three months to know if it's working for you. My patients say, oh my God, my sex dreams are back. Oh my gosh, my partner initiated, oh, this is so great. And the people it works for. It really is fabulous. And it's not that scary. It's been out 10 years. We've never had major any issues with the medication. It's like any other.
- [73:57]
Dr. Mary Claire Haver
Give it a try.
- [73:58]
Dr. Rachel Rubin
Right. If you are comfortable with Lexapro or Wellbutrin or any drug like that, Addi is very no different from the side effect profile. So the other drug is Valisi. It's an auto injector, just like your Ozempic. It's an auto injector that you give an hour before you want to want and it's a giant hit of dopamine. So it's on demand. So you get a huge surge of dopamine to your brain, a huge surge of dopamine to your genitals. We are publishing a paper right now that looks at is not just libido, it's arousal, it's orgasm. It's sort of all of these domains and Addie is too. So if you look at Addi, these are sex drugs. They help with arousal, they help with orgasm, they help with libido, and so they help with lubrication. So when you hit dopamine receptors, right, you can improve sexual health. Why have you never heard of these drugs? Because your doctor has never been taught about sexual medicine drugs. And if they don't think your sexual health matters, why would they have any risk conversation with you when they know that you're going to have sex whether you want it or not? And so if we think about and, and you must see this documentary, we're hoping it gets us distributor but you can do private viewing. So if you go to pink pillfilm.com you can get private showings. It talks about the fact that Viagra in 1998 was approved with fast track six month status because it was the most like, like cancer drugs go on this level because that's how important it was to get an erection. Drug approved by the fda, labansurin again was rejected twice. Then they said they met with the FDA and they said, here's a list of all the studies you have to do. The company did all the studies. And then the FDA was like, ooh, I know you did all the studies. And the data was clear that it works. But like, we can't really handle any risk at all because women might be driving carpool and what if they get sleepy? And could this be a date rape drug? And like, literally like the. You have to. The movie goes into all of the comments that happened and all the controversies and when you watch, it was only 10 years ago I was there, and.
- [75:49]
Dr. Mary Claire Haver
Viagra, it was like, well, he might have a heart attack, but he has an erect.
- [75:52]
Dr. Rachel Rubin
He could go blind. He could go blind. So there was one point in the movie, this is amazing. While they were trying to get this drug approved. And again, this drug works. And it. Does it work in everybody? No. Is this drug serious? No. Is the side effects bad? No. It's like a tool in my toolbox that I love using and works quite well. And so what's so crazy is while they were trying to get this approved, the 27th or whatever drug for men's sexual health gets approved by the FDA. It is studied in 1000 men. It's for penile curvature and the side effect is penile rupture. So your penis can extend, explode. And that is seen by the FDA as acceptable because if it makes your 30 degree curvature go to 20 degrees, that is a need and it gets approved right away. Whereas the FDA didn't approve, it took three tries to approve this drug that improves libido, decreases distress, improves more than just libido, but causes a little bit of sleepiness, which is why you take it at bedtime. I mean, you can't make this stuff up. And so there had to be advocacy around it. Just like there was advocacy around the black box of hormones changing because the labels were there for 20 years. Not because of the science, but because no one champions this topic to the level that they should be championing it. And the bureaucracy was just too hard to get through. The movie's just incredible because what happened, how the drug got sold and bought and what the small community that tried to get it through. It truly explains women's health in sort of a big, bigger picture of, well, there's always something more important, right? Your libido is not important to your doctor because we have to do your cancer screening and we have to do this and we have to do that and your mammogram.
- [77:32]
Dr. Mary Claire Haver
And nothing can affect your ability to have a baby.
- [77:35]
Dr. Rachel Rubin
Right?
- [77:35]
Dr. Mary Claire Haver
That is your fertility is the most important thing.
- [77:39]
Dr. Rachel Rubin
And if you say you're bothered by your low libido, you get told, you must do therapy. You have to fail marriage counseling. They're literally, Blue Cross is telling people they must fail marriage counseling in order to get Addie approved. I have never been told by a man's sexual health medicine, well, we will not approve that unless they fail marriage counseling. How about divorce? Take care of failed marriage counseling. It sounds like divorce to me. Like, how can you demand women get marriage counseling, which often isn't covered by insurance? And good luck finding a marriage counselor. No one in the sexual medicine world is suggesting that therapy doesn't work, that communication doesn't work. We love sex therapy. We love concepts. We love body positivity and sex education. But dopamine is dopamine, and dopamine works. So if you can say antidepressants cause sexual side effects, could medicine that works on the brain improve sexual health? Logic, people. It makes perfect sense. And that's what we find in our clinic. But there aren't enough doctors that are rolling up their sleeves, learning the nuances and writing the prescriptions, so it's easier to tell patients, well, sorry, there's nothing for you. There actually is. And we're just not using what we have because no one's even, like, having those conversations.
- [78:51]
Dr. Mary Claire Haver
There was a beautiful paper that came out last year, this year, like in the last 12 months. And it got presented at the menopause Society meeting. She was invited to present called I just don't feel like myself reading it and seeing that put on paper. And like, someone actually studied. This was a lightning bolt moment for me. I shared on the Internet. It went viral, of course. Idflm. You hear it all the time in clinic. I hear it all the time in clinic. How much of it? Like, a woman just comes in and is like, I don't feel like myself.
- [79:19]
Dr. Rachel Rubin
Now this.
- [79:20]
Dr. Mary Claire Haver
This is a woman who was previously feeling like herself, previously functional, had her stresses, had her marriage, had her kids, had an aging parents, had her job, had all the shit. But it was. She had it handled. And then all of a Sudden she is feeling like, I'm not handling this. Yeah, this is hard. How much of that do you think is due to hormones?
- [79:37]
Dr. Rachel Rubin
Getting to know people, talking to them, finding out their story, their timing, what's happening in their life, understanding how hormones work in the body. When. When I give women back hormones in their body in a evidence based way. The magic words that I. This is why I'm addicted to this work. Because over and over and over again, the women come back and they say, I feel like myself. Thank you. Refills, please. And that's it. Like, that's the magic words that I need to hear is, I feel like me. I don't need you to feel like someone else. I don't need you to be on all the things your friends are on or your neighbor is on. I care that you feel like you. And you know that you have the options and the toolbox to tinker with and play with until we get to what's right for you and we don't hit it out of the park every time. I wish we did. Right. It is not the same for each person, which is actually why menopause medicine is a little bit challenging, because it is not a one size fits all. And not everyone needs the same thing in the same way. But I find. And that's why I sort of. I love. I love estrogen and progesterone. I love testosterone too, because I can't unsee what I see in my clinic every day, which is about four to six months into their testosterone. It's not right away. It takes about four to six months of testosterone. I told this story to you earlier. I had a neighbor who was walking her dog and ran up to me on the street and said, Dr. Rubin, my testosterone finally kicked in. She'd been doing great on estrogen and progesterone. She said, my testosterone finally kicked in. I said, oh, fabulous. How long did it take? She said, five months. I said, great. I said, so what's up? She said, oh, I quit my job. I said, oh. She said, because I. I'm starting my own thing. She was so powerful. She felt like herself so much that she wasn't putting up with her toxic job that she left to start her own thing. And, like, that's amazing, right? And so that's what I can't unsee. So when a patient comes in saying, like, I don't feel like myself, it becomes, well, what do we have in our toolbox to help support you? Right? What is it? And what do we have now in 2025. What do we need in future years? Right. What's ahead and where can we play? And I think understanding it as. As shared tinkering, trying things out, figuring out what you, you know, what your body does well with what you like. Is it local hormones? Everyone needs local hormones to prevent UTIs, in my opinion. Is it whole body estrogen? Is it estrogen and progesterone? If you have a uterus or not have a uterus and you like it for sleep? Is it adding testosterone to help with libido, but helps with other things, according to my patients. Right. What is it that you need to feel like you? Is it something like a flibanserin or a brimalanotide for libido? Is it an antidepressant to help with anxiety and mood? Is it GLP1? Right. We're seeing a lot of interest in GL LP1s, and I think it's. It's getting the cocktail right? And in sexual medicine, cocktail is a pun there. It's getting the cocktail right so that it works for you in your life and you feel like you. And that's the magic. I mean. I mean, this is why I think we're all so passionate about this work, is because my patient who feels this, I want that for my next patient, and I want that for the patient after that. So when I have someone coming in nflm, I don't feel like myself. Well, I just saw someone who's ahead of her, who's feeling great, and I can now tell her, wait a minute. You have to hear about this story that just happened a few minutes ago, because I see that for you. I had a great reel just recently at a patient at my clinic who had been on estrogen and progesterone dead well for a long time. And she came to me initially and said, Dr. Rubin. And she was actually a DCIS patient, and she came to Mel.
- [83:02]
Dr. Mary Claire Haver
Carcinoma in situ. So stage zero breast cancer.
- [83:04]
Dr. Rachel Rubin
Yeah. So she was a breast cancer patient. She actually came to me years ago and said, I want hormone therapy. And I was like, oh, my God, you have breast cancer. I don't know. Like, here's the data. Here's what we know. Here's what we who don't know. We spent hours talking. We did a consult over and over and over again. We talked about it, and she decided, Dr. Rubin, I am an executive, and I need to stay hot. I am hot, and I am at the top of my executive game, and I don't want to change that. That is what is Important to me. My breast cancer has been treated. I feel good about this. If I get a recurrence, like, I listen, I. I'm already at a high risk for a recurrence. If it happens, we'll deal with it. I am, like, suffering from perimenopause. So we ultimately made a shared decision making situation. She started estrogen and progesterone. She did great for years. Years. Okay, years. And I was always like, do you want to try testosterone? Like, people like it for libido. They like it, you know, for many different things. She's like, nope, I need to stay hot. I can't possibly have hair loss or acne and I will not take testosterone. I said, listen, like, you know, I think more people never start testosterone because they're afraid of the side effects than actually get the side effects and stop testosterone. It's not saying that testosterone doesn't have side effects, but rarely do I have patients saying, oh, my God, I'm bald now. You know, again, pellets are high doses. I don't use those. I use lower doses and topical testosterone. And so finally she tried it about two years ago, she tried it and I made a reel because she was in my clinic last week and she was like, God damn it, you were right. I should have done this years ago. Like, I am finally back to me. I feel great. I'm still hot. I'm still a high, high powered executive. And this is. She kept using the word tremendous. This is tremendous. And you can hear her on the real, because I'm talking about her and she's in the background talking too. And she was excited to make that real. She was excited to tell people about it. Right. Of this idea of like, well, I want other, other women to experience. Which she and her case is not an easy case. It's actually a very challenging case. But she made the choice and we work together to kind of figure out what she needs to feel like her and that matters.
- [84:57]
Dr. Mary Claire Haver
Where does testosterone matter most in this, like, cascade? Because, you know, female sexual function is like, I like to describe it like a traffic circle. And there's several like, pathways in there. We have elasticity, we have lubrication, we have pain, we have libido in the brain. We have all these things. Is testosterone kind of lubing that whole wheel?
- [85:15]
Dr. Rachel Rubin
I think there's local topical testosterone, like your vaginal dheas that can help with the bladder and the urinary symptoms. Testosterone form DHEA is the closest thing that we have at this point that's FDA approved. There Are some of us who will do a topical, a low dose compound, not for libido, but for that vestibule tissue that's a common compound. I don't compound a lot of things, but that's one area where I will. So we don't have a lot. We need more data. There actually is quite a bit of data on testosterone for GSM and we need more of it. And so it is a really important, important area of research.
- [85:44]
Dr. Mary Claire Haver
Menopausal patients, like, yeah, like when it's very rare that people actually study a woman who's postmenopausal.
- [85:50]
Dr. Rachel Rubin
And when you do vaginal testosterone, you do see improvements in arousal, orgasm, libido and things like that at different doses. So it's a very interesting area of study where I work with patients. I take the time to meet them where they are and give them what they need and give them the toolbox. And so it's not a one size fits all. And we figure out where to start. We figure out, is it your hot flashes that are the thing that's driving the crazy? Are you not sleeping? Is your sexual health the thing that's driving this? And it's kind of what is the right formula that's going to help maximize your quality of life? Because that's all that matters, right? I lost my mother back in November and quality of life, like to me, we are all going to die. And dignity, the dignity of life is so important. And so we don't talk about it enough. And so I don't care how many years I live, I want to live good years. And my grandmother had dementia and osteoporosis and broke all her ribs when my grandfather gave her a hug. Like, I don't want that life. And so my patients don't want that life. And patients are reason. No patient is saying, like, well, I have to live to 103, you know, at all costs, you know, like no one cares about that.
- [86:52]
Dr. Mary Claire Haver
They want, they want to age with dignity.
- [86:54]
Dr. Rachel Rubin
Yeah.
- [86:54]
Dr. Mary Claire Haver
And so simple.
- [86:56]
Dr. Rachel Rubin
So it's so simple. So the question. And it's okay to tell patients, like, we don't know what your longest path of dignity is. It's okay to say you don't know. In fact, I've made a career off of saying I don't know. And we don't have data for that. And so it's okay to tell a patient, I don't know if your breast cancer, cancer is going to kill you or if dementia is going to kill you. I don't know what's Going to hurt your dignity the most. So I'm making the best decisions with you that I can. And I might be wrong. And that's what patients want to hear. They want to. They want to know that you don't know everything. They want to know that they may have options. And they want to understand what's going on. And it's okay to say, here's what we know in 2025. Here's the data, which actually, it's like the stock market. We're betting on it, right? So I think of hormones as, I think of peptides as. As like, crypto, right? So, like, I think of, like, I think of it like that's crypto. So if you're putting all your money in crypto and everything you do is peptides, like, you're a crypto bro. Congratulations. I think good exercise and nutrition is kind of like your, your like, savings. It's like your high yield savings account. Everyone should have one, have an emergency fund. Like, those are things you should do. I think hormones might be like your, your, like, investment portfolio might be your 401k of like, I want, you know, like, and it's okay, right? Like, as your thing of day. Diversify, right? Diversify your portfolio. So take care about your nutrition, care about your connection to people, care about your mental health, care about your sexual health, right? Hormones might be a part of that diversification. And if you're curious about some of the, like, you know, bro science and stuff, like, sure, dip a little in crypto if you want to. Knowing that crypto's risky, right? And that's what I think all of this conversation can be. So doctors need to do a better job. We're not perfect, you guys. We're human. We have egos, we have lives. We're busy. We're not trained on this. The system is broken, like, literally. Your doctors, if you can find human, human qualities to your doctor, you're winning because the doctors are broken down and tired and having trouble, and they need a little empathy, too. So do you as a patient. But so if the doctors can do a better job of just saying, hey, I'm working my best to make your portfolio as diversified as possible. But there's, as your finance, as your health advisor, like your financial advisor, I don't have the crystal ball. I don't know what is going to, like, that's why we diversify. And so that's where those conversations really need to happen.
- [89:08]
Dr. Mary Claire Haver
So, you know, a lot of questions I'm sure are going to come from the Audience of like, am I on the right mix? Can I take. You know, there's a lot of misconceptions around. Well, my doctor says I can't have vaginal estrogen because I'm on systemic. I don't need testosterone because no one was trained on how to give it. And actually, you taught me how to do it. Thank you very much. What's the right formulation? Do women need all of them? Can you take all of them together?
- [89:29]
Dr. Rachel Rubin
This is the challenge of podcasts and more importantly, Instagram. Right. This 90 second reel is not necessarily gonna answer your specific. And that's what's so heartbreaking, because your doctor may not be answering your specific question. So you want to get it from Dr. Mary Claire. You want to get it from Dr. Kelly Casperson. You want to get it from myself. And it's so hard to give that. We can't give that individual story because we really do need to get to know you. I have a course where I teach clinicians how to prescribe hormone therapy. And they've been wildly interested and successful. And it's working when you teach them sort of how to do it. And so I teach them that there's really five things to consider, and you can do some of them by themselves. You can do them all together. But really, you as a patient have, I would say, five hormone things on your menu. It's gonna be whole body systemic estrogen, whole body systemic progesterone, especially if you have a uterus. You have to protect that from uterine cancer if you're gonna use estrogen. Now, some people say it helps with sleep and it helps with mood. And some people without a uterus take it whole body testosterone therapy, which is global consensus that it helps with libido and is approved in Australia and New Zealand. And so if it's safe enough for them. Give me a break. It should be safe enough for our Americans. So that's whole body three, estrogen, progesterone, and testosterone. That's three things. Then there's vaginal hormones, which are needed even in the setting of systemic hormones and should and can be used without systemic hormones. Vaginal hormones prevent urinary tract infections, help with the genitourinary syndrome of menopause, and are safe for everybody on earth to take. And the fifth thing, which is sort of extra credit, and y' all are so smart. You learned about it today on this podcast, is that vestibule. And so sometimes even with vaginal hormones, that area around the urethra still be a little spicy. And so if you're still having pain with penetration, even though you're on vaginal hormones, you may need to put a little topical on that vulvar vestibule or switch to a vaginal DHEA to help with that vestibule. So that's extra credit. So when I teach doctors and other clinicians on this course, we go through each of these modules and we really talk about, okay, well, when you're counseling a patient, what are you afraid of? Right? That's how I teach hormone therapy is I want every doctor and clinician who writes prescriptions say, well, can I use it in this patient, can I use it in that patient? How about a 64 year old who has this, that and the other? And my answer back to that is, what are you afraid of? Are you afraid of stroke, blood clots, heart attacks, dementia? Like, what are you the most getting sued? Or are you just afraid that you don't know how to write the prescription and how to follow that patient? What are you afraid of? And we go through that idea of like, how can we give you the confidence to know that transdermal hormones don't have the same blood clot risks as an oral hormone therapy? How do we teach doctors and clinicians to know that we don't necessarily have all the data in the way world on dementia, but if your patient has osteoporosis and, or osteopenia and wants to prevent osteoporosis, then why is one more, you know, like, like we use the data that we have and the logic that we have instead of the data that we don't have. And so I help doctors and clinicians use the data that we do have to really make educated, logical decisions and share decision making with the patient in front of them. And so it really becomes, what are you afraid of? And I, I love that and you know, I love that sort of thought process because it pushes them to say, like, well, would you do it? Like, why? Why are you afraid? And really question that. And so for your doctor who says you can't have this, your question back to them is, well, what are you afraid of? And what does the data actually show? Are you afraid because you don't know how to do this, or are you afraid because you're unclear at the updated data that sort of exists and the way it's been interpreted now? And so, and then, you know, it's really teaching that you can do all of the things in the toolbox, you can do some of the things in the toolbox, but you deserve as the patient to do know what your toolbox is.
- [93:08]
Dr. Mary Claire Haver
So right now most men can walk into any clinic. Actually there's whole clinics on sidewalks I see with giant signs where they can go and get an evaluation for sexual dysfunction. And women are struggling to get the same level of care. And women in most clinicians office are told that the majority of their issues are psychological. But now that they listen to this podcast, they're realizing that this is probably biology and less psychology. But why do you think because you, you have a foot in both worlds, male and female medicine. Why do you think that. That there's this double standard, it's research and science.
- [93:38]
Dr. Rachel Rubin
I mean it's that the, it's that.
- [93:40]
Dr. Mary Claire Haver
We have more valued.
- [93:41]
Dr. Rachel Rubin
We, we haven't put any effort into women's sexual health the way that it deserves. And so it's really effort. It's rolling up our sleeves and doing the work and everyone wants the work to magically happen. But it's like I want my kitchen to be clean, but unless I sort of roll up my sleeves or my husband rolls up his sleeves and we actually clean the kitchen, it's not going to get done. And research is no different. We can pray and want it to be better for women, but I need those people to go into basic science. I need them advanced clinical science. I need them to do more research, I need them to get funding, I need PhDs to come work with us. I need interested industry partners to get excited and interested. This is half the population. So there is money to be made here from an industry perspective, but you have to do the work and the science deserves the work. Women deserve science. They don't realize it because all they've ever gotten is snake oil. But they need good science and we need to invest in that just like we have for men. So it's not a fluke that, oh, look at, we have 27 products. And for men, for sexual health, of course we do. We studied it, we bothered to look at it. And so men's sexual health is biopsychosocial, right? I can't take your brain and your life and how you think about sex and sex education out of your life. It's biopsychosocial. Guess what? We're homologs. We talked about that at the beginning. We're all the same, right? Biopsychosocial. And so you deserve. If sexual health is important to you, it should be important to your doctor and it should be important to science. And that's where we fight and we fight and we keep fighting because There are more important things to our society, but this is. This matters to you. It matters to your relationship, and it should. And that's why we need more people to be able to do this. It is a blessing to be able to do this work. But I am incredibly frustrated with my limited toolbox and my limited other people who are helping.
- [95:26]
Dr. Mary Claire Haver
How does this show up in insurance?
- [95:27]
Dr. Rachel Rubin
Oh, my God. Don't even get me started. Right?
- [95:29]
Dr. Mary Claire Haver
Get started.
- [95:30]
Dr. Rachel Rubin
When I left fellowship, right. It became, oh, I couldn't get hired, Mary Claire. Like, I couldn't get a job. The academic centers said, what you do is weird, and you will not make us enough money fast enough. The private equity.
- [95:42]
Dr. Mary Claire Haver
That's why I had to leave the academic institution to go do menopause care. You will not make enough talking to patients.
- [95:47]
Dr. Rachel Rubin
The private equity urology practice, they handed me a contract and they took it away from me. Yeah, you know, if you're listening, you know who you are. They took it away from me and said, you will not make us enough money fast enough. I couldn't get a job in the insurance world because I wanted to spend time with people and actually help problems. And so, yes, many of us have had to go out of the insurance world to be able to. To spend time with people, spend two hours with people, which is why our wait lists are so long, because there are only so many hours in the day. And I have two small children, right. So we had to have other people come help us do this, and we have to train more people to do this. But medical system is not set up for your sexual health needs. And so we either change the system or we, you know, try to figure it out. And so we're working hard to teach more people how to do this. But if we don't fundamentally change how much time we can spend with people, then we're in trouble. That an insurance company, and he's like, give me a break. You know, these.
- [96:38]
Dr. Mary Claire Haver
These reimbursement rates favor procedures and not talking. Dermatologists make so much money. Not because they're sitting there talking to a patient, because they're literally every. Every patient is a procedure. And like OBGYNs make money doing. Delivering babies and doing surgeries and procedures. Like your well, woman exam pays $30 with a doctor.
- [96:57]
Dr. Rachel Rubin
People just want to feel better. So people don't want to hear doctors complain and doctors be upset and have burnout. But the reality is, is we live in an economic society. We live in a capitalistic society, and your doctor has to make money in order to feed their family. And the hospital system has to make money to stay, keep the lights on and to keep paying everybody. And so the math has to math. And so when we're talking about that, your sexual health is never going to make the math math. What makes the math math is the orthopedic surgeries and the neurosurgeries and, and, and the deliveries and things like that. And so we cannot have this conversation without the bigger conversation of your insurance company doesn't want to pay for it. They don't want to pay for your. So it becomes how can we support sexual health and pay for men not. Not as they are. Yes, yes, but even that actually, no. And it's. Right, it's, it's actually limited too. In fact, I wish, again, I wish I could say Ben, have it all easier. Urologist. Now, if a man comes in with erectile dysfunction, many insurance companies will not pay unless they have like a urinary problem or a prostate problem or, or something like that. And so we even see the problems. And actually the fda, we just did a big panel, right, about women's hormone therapy. The FDA this month is to. Going, going to be doing a panel on men's hormone therapy because there actually are very similar challenges and problems within the men's health world. And so I want people to keep an open mind because we love to say, like, oh, women have it horrible and men have it great. They actually don't. When it comes to sexual health, it's just better than. It's just 30 years ahead in women's health. But it's far less than the cardiology research or the orthopedic researcher, you know, the sexual medicine urologists. Like, we're still kind of low in the pecking order than like your, your cancer doctors and like your, your reconstructive doctors and things. Sorry, friends, I know, you know, they're not listening. Anyway, it's okay.
- [98:37]
Dr. Mary Claire Haver
What is exciting you most about the future? What innovations?
- [98:40]
Dr. Rachel Rubin
I am just excited to be alive in 2020. Like, like, I, I can't believe this year has happened, right? Like to, to live in a time when the box labeling gets removed on hormone therapy. Like, I'd never in my life thought I would be alive to see it and yet to be on stage getting to help announce it. Like, my wildest dreams. Couldn't have dreamt something like that to be able to help with the guidelines for genital urinary syndrome of my.
- [99:05]
Dr. Mary Claire Haver
But there was pushback, right? Pushback from institutions, pushback from individuals. Why do you think that was? I Mean, those labels never should have been there. The science wasn't sciencing.
- [99:13]
Dr. Rachel Rubin
Okay? So the, as your listeners know, the Women's Health Initiative comes out in the early 2000s. There's a press conference that said hormones are going to kill you. They're going to cause cardiovascular disease and breast cancer. And there's a press conference and everyone threw their hormones in the garbage. With that press conference, the FDA put a warning label on. There was no advisory committee, there was no group of experts that came and read the paper and highlighted it and said, wait a minute, the data says this. So the label should say that there was no consensus. They just poof. Put a label on that said all hormone products cause stroke, blood clots, heart attack, probable dementia and cancer. Okay? And that has been the case for 20 years. Even that study published this year, that below 70, there was no statistically significant increase in stroke, in stroke or blood clots or heart attacks. Below 70, below 70. So the data that the box was based on never actually really said what the box said. And the box labelings are there for life threatening harm, okay? Life threatening harm. Hormone therapy, it's like cyanide. We can talk about the risks and the benefits and the who should use it and who shouldn't use it and the nuances, but a box label that is like this will kill you immediately. Give me a break. It was never supposed to be on there in the first place. And the reason it was there for 20 years. Oh my God, 20 years. Is not because of the science. It is not because science said it was true. It's not because your doctor knows something that you and I do not know. It is because of inertia. It is because of bureaucracy. It is because there were always more important issues to tackle. And so nobody did it. They were asked, right? The Mental Health Society asked. In 2014, the FDA took two years to respond and just said, we don't want to deal with it right now. We went back in 2024 and they said, yeah, it's going to take, you know, there's politics, there's bureaucracy, all of this stuff. And when we left that meeting in 2024, the, the, the a public person at the FDA whispered in our ears. She's an amazing woman. She whispered in our ears. She goes, go get loud. She said, go get loud. Go to the mattresses, get loud. Get your congress people involved. And that's what we did. We got, we got so loud. And thank you for all of your loud voice. Right? We needed everybody and we got loud and we did advocacy and we had petitions and we got people and we talked to our legislative people and we, we just got loud. The journalists got involved, involved. And then right again in 2025, Marty McCary said, this is something that's important to me. And he got on every news channel, the head of the FDA got on every news channel and said, hormone therapy is important and these labelings do not make sense and we're removing them. And so again, testosterone had a warning label for men. Okay, this is important. Testosterone had a warning label put on. And the warning label said it caused, yes, stroke, blood clots, cardiovascular disease problems. There was an advisory panel to put the label on. So met, they talked about it, they put it on. Remember, no advisory panel to put the estrogen label on. And then the FDA because of that advisory panel said, do this five year long study, prove this, this, this and this, and we'll remove the label. So what happened? The companies came together, the people came together and they did a five year study called the Traverse trial. The Traverse trial came out and within just a couple of, you know, months or, you know, with the Traverse trial out, they removed the label with no advisory panel and there was no controversy, there was no one cared. They said they did the study, they removed it. There was no advisory panel find the is now gone estrogen, right? They remove the label and there is some pushback of, oh, they didn't do enough to like make sure it was the right move. But the label never should have been there in the first place, right? No one. There's no data to say that what the label said warrants being on a label. If they didn't remove the information, the data is still there, right? The relative risk and the absolute risk and what the women, it's all still in the label. Read the label people, once they update it, it's all still there. And so people getting, I'm like, this is just saying hormone therapy is a nuanced discussion that you should have with your doctor who should know the data. And we should be teaching in medical schools and residencies. And it shouldn't just be your ob gyn, it should be your urologist, your neurologist, your orthopedic surgeon, every doctor, your primary care doctor who takes care of women. Every doctor who takes care of women should know about hormone therapy and be able to counsel appropriately. That's all we're asking. And so for the FDA to remove that warning label is massive because so many people were able to up warning label. I don't have to do this. Sorry, not my thing. Right? And now the head of the fda, a man gets up on every news channel and says, this is. I'm a surgeon. This is your lane. This is my lane. We have to know this. And that's revolutionary. So, yeah, I'm going to get on stage and cheer for that, and sign up for that and say, yes, this is good for people. Do we have to help teach people the nuances and the details? Of course we do. That's where my friends can all step up and say, there are nuances and there are details and we need more research. That's what we're all here talking about. But women deserve the opportunity to have the conversation.
- [104:12]
Dr. Mary Claire Haver
What is one step that. That she can take tomorrow to begin reclaiming her sexual. If she is not happy, she's like, my sex life, My sexual experience is not where I want it to be. Where does she start?
- [104:25]
Dr. Rachel Rubin
The most important thing here is it is not anyone else's job to make your sex life good. It is your job to make your sex life good. And so you must do the work that it takes to make sure. Sure you are having the best sex possible that you want to be having. Too often, people are having bad sex because they're just having sex for their partners or they're doing what their partners want. They expect prince, the prince or Princess Charming to come and fix all their needs. But the reality is, is you have to use your words. You have to learn your body. You have to know what works for you, and you have to have the fun that you want to have, and you have to change and know your body's going to change. And so you have to be resilient and continue to have fun in the face of problems. And so that's what we do, is try to figure that. And that comes with learning. Learning about your body, how it works, learning the biology, learning the hormones, learning. The more you learn about your sexual health, the more you can tinker with it to say, what can we do to have more fun? And remember, sex is supposed to be fun. We are reproducing in, like, a very short period of time in our lives. And so if sex is important to you, it's important because of connection and pleasure and orgasm and joy. And so the question is, if you're having bad sex, that's on you. You gotta find joy. And if that sex is not joyful for you, you will not die. No one has ever died because they didn't have an orgasm. Right? No one has ever died from not having Sex. If you don't want to have sex, do not have sex, right? If you want to want, if you care about sex, if you want to not have pain in sex, then you deserve like options and doctors and, and, and, and people in your medical team that can help and really support you.
- [105:55]
Dr. Mary Claire Haver
Where is the best place for them to start to look? To find a sexual medicine expert or someone that can help them?
- [106:00]
Dr. Rachel Rubin
Yeah, I'm, I am very biased here. I love isswish. Iss you can find a provider. They have a patient facing website called Procella which also has find a provider. But really these, these are, we are a 1500 person scrappy group that just cares about women's sexual health. And so if you're a clinician, we need you, we want you join us. Our meetings are awesome. The educational courses are awesome. The people, it's multidisciplinary. So if you're a physical therapist, a mental health professional, a doctor of any kind, a nurse practitioner, like we love everybody. You can have leadership positions, your students, we love your research. We want you to get involved and so really, really encourage people to use that as a place. And we need more funding, we need more people showing up. So for industry partners, please join us. Like this is a fun. You've been doing ISWish conference, have you? Virtually. They're just so fun. Like if you ever watch us on Instagram, you're like, oh my God, how is a medical conference this joyful and fun?
- [106:58]
Dr. Mary Claire Haver
It is off the chain. And all the little fun little things that you get to take become clitorises and vibrators. I mean they're throwing vibrators at you. It's, it's kind of amazing.
- [107:07]
Dr. Rachel Rubin
It's not a bad day when that happens actually.
- [107:09]
Dr. Mary Claire Haver
So if I gave you a billion dollars and said what are we going to study?
- [107:13]
Dr. Rachel Rubin
So my dream, I have a lot of dreams, but my dream is really.
- [107:17]
Dr. Mary Claire Haver
To someone gave you a blank check.
- [107:18]
Dr. Rachel Rubin
Make your perfect sense. I think we need a little NIH for sexual health because the NIH is never going to fund orgasm research or sexual health. My dream is really to have, have scientists and multidisciplinary clinicians who are studying the things people care about. Orgasm, arousal, hormone therapy, pelvic pain. We need basic science money. We need a physiologic. I want a sex lab. I want an orgasm lab. I want, I want to put people, hook up people up to wires. I want to understand the science. I want to do brain scans. I want to, I want the science to be science. And the body to be science and us to look at that. I want wearables. I want to study wearable technology. I want to understand how hormones work in people's bodies. I just think, like, with, like we see with science, when you put people, smart people together in a room that do different things, you can figure things out much quicker. And we are so behind in sexual medicine for everybody that we do need an influx of interest in this space. I need smart. I need to be surrounded by smart people who can ask interesting questions. It's never going to have, like, we're never going to have an institute at the NIH for sexual health. But can I. I'm in Washington, D.C. so can I create like a little one? Can I do like a mini, Like a mini one? Because there really are unlimited questions here, which is what makes this so joyful and fun. Because we can really make impact and learn things, you know, quickly, even from basic anatomy things. We're learning new things every day.
- [108:42]
Dr. Mary Claire Haver
Well, Dr. Rachel Rubin, this has been incredible. I'm so happy you came and shared all your incredible knowledge. I feel like we could have gone for another couple hours, but sadly we have hard stops and have to get on airplanes and things and trains. Thank you so much and we'll have.
- [108:56]
Dr. Rachel Rubin
To have you back. Oh, thanks for having me.
- [109:00]
Dr. Mary Claire Haver
You can find Dr. Rubin on Instagram and YouTube at Dr. RachelRubin and on her website, rachelrubinmd.com where you can learn all about her education, research and advocacy efforts. You can find full episodes of unpaused on YouTube at Dr. Mary Claire, I'd love to hear from you about this topic, topic, or anything else that's on your mind. You can find me on Instagram rmaryclaire and get honest, accurate information on health, fitness and navigating midlife@thepauselife.com My new upcoming book, the New Perimenopause is available for pre order on Amazon. If you're loving this podcast, I have an important request. Please take a moment to follow Unpaused on your favorite podcast app. Following and listening is what pushes this information to more women who need to hear it. So if this podcast has helped you feel seen, understood or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going. Unpaused. Unpaused is presented by Odyssey in conjunction with pod people. I'm your host, Dr. Mary Claire Haber. The views and opinions. Opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related material.
- [110:23]
Dr. Rachel Rubin
In the wake of artificial intelligence, how do we approach securing the software we build? The answer lies in collaboration, not just across teams, but across companies, industries and disciplines. Join us on a new season of Compiler, Red Hat's original podcast, exploring important tech topics beyond the buzzwords. And this time around, we'll cover the fundamentals of product security. We'll discover how security professionals work together to encourage innovation with security in mind. Compiler is available on all major podcast platforms. Hi, I'm Amber Emily Smith, and I'm the author of the Girl on the Bathroom Floor.
- [110:57]
Dr. Mary Claire Haver
This book is for anyone who feels like their life has not gone the way that they had hoped.
- [111:01]
Dr. Rachel Rubin
It's for anyone who feels like everything.
- [111:03]
Dr. Mary Claire Haver
Around them is falling apart.
- [111:04]
Dr. Rachel Rubin
For anyone who has been through or is going through a dark, deep season of pain.
- [111:10]
Dr. Mary Claire Haver
It's about grief, it's about hope, and it's about our good and gracious God.
- [111:13]
Dr. Rachel Rubin
Who meets us in the Valley.
- [111:15]
Dr. Mary Claire Haver
You can listen now on Spotify. Are intended to be a substitute for professional medical advice, diagnosis, or treatment.