Podcast Summary
unPAUSED with Dr. Mary Claire Haver
Episode: Menopause, Hormones and Women’s Sexual Health with Dr. Rachel Rubin
Date: January 27, 2026

Overview
This episode features a dynamic, deeply informative conversation between Dr. Mary Claire Haver and Dr. Rachel Rubin—board-certified urologist, sexual medicine specialist, and advocate for evidence-based women's care. The pair tackle the state of women’s sexual health in midlife and beyond, dissect the failures and biases of the medical system, and provide empowering, actionable advice for women seeking to reclaim or optimize their sexual well-being.

Dr. Rubin brings unparalleled expertise in the overlapping areas of urology and sexual medicine for all genders, revealing how lack of medical education and research, systemic sexism, and flawed health policy impact the quality of sexual healthcare women receive. The episode breaks taboo topics with candor, compassion, and plenty of levity—demystifying anatomy, treatments, diagnosis, and access.

Key Discussion Points and Insights

1. The Crisis of Women's Sexual Health in Medicine

   • Dr. Rubin highlights the unrealistic expectations placed on OB/GYNs to manage all aspects of a woman's health in quick yearly visits.
   • “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.” (10:14, Dr. Rachel Rubin)
   • Urologists are often not considered for women’s care, despite their expertise in organs shared by both genders—kidneys, bladders, and genitals.

2. Training Gaps and Research Neglect

   • There are 27+ sexual medicine fellowships for men, but just 2-3 for women.
   • “The reason your doctor doesn't know how to talk about libido, arousal, orgasm, or pain is no one ever taught them.” (09:20, Dr. Rachel Rubin)
   • “I learned nothing. Like, literally nothing.” (09:20, Dr. Mary Claire Haver)
   • NIH sexual health research—especially female orgasm—lacks funding, infrastructure, and interest.

3. Anatomy, Pleasure, and Pain: What Women Aren’t Taught

   • Most clinicians can’t draw the clitoris accurately.
   • The clitoris and penis are "homologs"—formed of the same tissues, similarly innervated and responsive to hormones.
   • Misunderstandings about this anatomy result in poor sexual satisfaction, surgical injuries, and dismissing women’s pain as "psychological."
   • “No man comes to see me and says ‘Doctor, I’m broken, I rub my thigh and I can’t orgasm.’ But that is basically what women are told.” (20:29, Dr. Rachel Rubin)

4. Consequences of Poor Sexual Health Training

   • Women are frequently misdiagnosed or dismissed when presenting sexual complaints.
   • “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.” (12:14, Dr. Rachel Rubin)
   • Systemic focus on cancer risk and reproduction leaves women’s happiness, pleasure, and quality of life unaddressed.

5. Painful Sex: Diagnosing Beyond the Surface

   • Pain is not normal and must be properly diagnosed—not dismissed as stress or “just needing to relax.”
   • The vulvar vestibule (the "rim of fire") is critical: hormone-sensitive, often overlooked, and a frequent source of pain.
   • Key quote: “If you were never taught to look for something, you're never going to find it.” (31:01, Dr. Rachel Rubin)
   • Pelvic floor muscles are often at play—pelvic floor therapy is crucial for many women.

6. Genitourinary Syndrome of Menopause (GSM): Beyond Vaginal Dryness

   • GSM includes urinary urgency, frequency, infections, and sexual symptoms—the new guidelines stress it's due to a low hormone state (not just estrogen, but also androgens).
   • These symptoms begin not just in menopause, but may arise in perimenopause, postpartum, and from hormonal contraception.
   • “Vaginal hormones... are safe for great grandma and they prevent urinary tract infections... If we gave women in Medicare vaginal estrogen, just prophylactically... we could save Medicare between 6 and $22 billion a year.” (47:55, Dr. Rachel Rubin)
   • Local vaginal hormones help prevent UTIs and improve sexual function, with negligible risk.

7. Medications with (Negative and Positive) Sexual Side Effects

   • Birth control pills can diminish libido and cause pain by lowering testosterone; spironolactone and some acne drugs can dry out tissues and decrease arousal.
   • Antidepressants (particularly SSRIs) are well known to dampen libido and orgasm.
   • New drugs for low libido exist for women—Addyi and Vyleesi—but doctors rarely discuss or prescribe them, and insurance access is minimal.
   • Notable moment: Men can get drugs for sexual function rapidly approved (27+ medications), but women’s drugs face extreme FDA skepticism and bureaucratic obstacles.

8. The Role of Testosterone

   • Testosterone is vital for libido, clitoral integrity, and genitourinary health; yet access and expertise in dosing for women is limited by lack of FDA approval in the U.S.

9. Systemic Barriers: Insurance, Time, and Economics

   • The system doesn’t incentivize time-consuming, non-procedural medical care—leading providers to limit time for women’s sexual concerns or opt out of insurance networks.
   • “Doctors, if you can find the 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.” (86:55, Dr. Rachel Rubin)

10. What Can Women Do?

• Sexual health and pleasure must be self-advocated—it is not someone else’s job or your partner’s responsibility.
• “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... you have to use your words. You have to learn your body.” (104:24, Dr. Rachel Rubin)
• Seek out specialists—use ISSWSH’s ProCella provider finder to locate sexual medicine experts.

11. The Future: Advocacy, Research, and Hope

• Dr. Rubin dreams of a "mini-NIH for sexual health" to support physiology, hormone, and pleasure research.
• Successes: removal of FDA black box warning labels on hormone therapy, new multidisciplinary guidelines for GSM.
• What excites her most: “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.” (93:41, Dr. Rachel Rubin)

Notable Quotes & Moments with Timestamps

• “Nobody expects me to take care of all of a man's health needs... So the mere fact that we have OB GYNs and they are expected to take care of a woman once a year... is unconscionable.” (00:00, 10:14, Dr. Rachel Rubin)
• “The reason your doctor doesn’t know how to talk about libido, arousal, orgasm, or pain is no one ever taught them.” (09:20, Dr. Rachel Rubin)
• “No man comes to see me... ‘I rub my thigh and I can’t orgasm.’ But that is basically what women are told.” (20:29, Dr. Rachel Rubin)
• “Pain is not normal. You should never have pain with sex. Penetration shouldn't hurt, tampons shouldn't hurt... you must get a diagnosis for why you have pain.” (28:45, Dr. Rachel Rubin)
• “Vaginal hormones... are safe for great-grandma and they prevent urinary tract infections... we could save Medicare between 6 and $22 billion a year.” (47:55, Dr. Rachel Rubin)
• “If sex is important to you, it’s important because of connection and pleasure and orgasm and joy. If you’re having bad sex, that’s on you—you gotta find joy.” (104:24, Dr. Rachel Rubin)

Timestamps for Important Segments

• [06:09-10:14] Dr. Rubin and Dr. Haver discuss career paths, urology’s fit for women
• [12:13-15:02] Systemic dismissal and minimization of women’s sexual health complaints
• [18:02-21:34] Detailed, humorous, and practical talk on clitoral anatomy and pleasure
• [21:51-23:56] Surgical mishaps and ignored effects on orgasm due to poor anatomical education
• [27:17-32:01] Case study on vestibulodynia and the importance of diagnosis
• [34:34-36:14] Pelvic floor muscle causes of sexual dysfunction and importance of PT
• [40:02-47:43] Genitourinary Syndrome of Menopause—definition, symptoms, role of hormones
• [54:56-56:50] Sexual side effects of antidepressants, nuances in counseling, lived experiences
• [62:25-65:43] Birth control, informed consent, and links to sexual side effects
• [71:05-77:31] Medications that boost desire: Addyi, Vyleesi, the FDA approval saga
• [99:13-104:24] FDA black box warnings, legislative and media advocacy, what changed
• [104:24-106:57] Action steps: self-advocacy, where to find clinical expertise

Actionable Takeaways

• Pain with sex, penetration, or tampons is NOT normal—seek a diagnosis, don’t accept dismissal.
• Vaginal hormones (estrogen or DHEA) are safe for nearly all women, prevent UTIs, and should be considered, especially beyond menopause.
• Learn your own anatomy and check your sexual expectations against biology, not pop culture.
• Ask for a referral to a sexual medicine specialist; use the ISSWSH ProCella site to find one.
• If your provider dismisses your sexual health concern, ask: “What are you afraid of?” and “What does the current data actually say?”
• Demand and participate in shared decision making regarding hormone use, contraception, and sexual side effect counseling.

Resources Mentioned

• ISSWSH (International Society for the Study of Women’s Sexual Health): https://isswsh.org
• ProCella provider finder: https://www.procella.org
• Dr. Rachel Rubin: https://rachelrubinmd.com | IG/YouTube: @DrRachelRubin
• Dr. Mary Claire Haver: IG: @RMaryClaire | https://thepauselife.com

Tone
Bold, irreverent, truth-telling, science-based, and empowering—all while making heavy, under-discussed topics accessible and even fun.

For further questions or personalized care, listeners should seek out certified sexual medicine practitioners and discuss treatment options and sexual side effects openly with their healthcare providers.