#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
May 12, 2025
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Dr. Rachel Rubin is a board-certified urologist and a leading expert on sexual health, particularly for women. She discusses the often-ignored complexities of women’s sexual health, hormonal changes during menopause, and the critical need for personalized hormone replacement therapy (HRT). Dr. Rubin clarifies misconceptions surrounding HRT and emphasizes the benefits of local vaginal therapies. She also highlights the significant health risks of menopause, including osteoporosis and cognitive decline, advocating for improved awareness and education in this field.
Dr. Rachel Rubin emphasizes the critical neglect of women's sexual health in traditional medicine, highlighting the importance of addressing this issue systematically.
The podcast discusses the complex physiological changes that women experience during menopause, particularly the abrupt hormone shifts that significantly impact their health.
Hormone replacement therapy (HRT) is demystified as Dr. Rubin challenges misconceptions, advocating for its safe, personalized use to enhance women's quality of life.
The importance of local vaginal hormone therapies is highlighted, offering substantial benefits for managing urinary health and improving sexual function in menopausal women.
Listeners are encouraged to seek knowledgeable healthcare providers for effective hormone therapy management, emphasizing the need for individualized treatment plans in women's health.
Deep dives
Translating Longevity Science
The podcast emphasizes the goal of making the science of longevity and health accessible to everyone. The host, Peter Atiyah, stresses the importance of high-quality content provided without relying on paid advertisements. This approach aims to educate audiences on health and wellness while ensuring that members receive exclusive benefits and information that surpasses what's available for free. The team dedicated to this mission plays a crucial role in delivering insightful content that empowers listeners to make informed health decisions.
Women’s Sexual Health Overview
Dr. Rachel Rubin, a leading urologist in sexual health, discusses the significant neglect of women's sexual medicine in traditional healthcare. Highlighting the differences between male and female experiences of hormone decline, she explains the physiological changes involved, particularly in the menstrual cycle and perimenopause. The conversation addresses the critical risks associated with menopause beyond common symptoms, leading to conditions like osteoporosis and cardiovascular disease. These insights underline the urgent need for better understanding and treatment of women's sexual health issues.
Menopause and Hormone Fluctuations
Menopause is characterized by a drastic loss of sex hormones, leading to various symptoms and health risks. The podcast uses the analogy of a gas tank to describe how men’s aging hormone decline differs from women’s abrupt hormonal changes, particularly during perimenopause. As women transition, they experience erratic hormone fluctuations, contributing to a wide range of symptoms. Understanding these fluctuations is essential for managing and treating menopausal symptoms effectively.
Effects of Hormones on Health
The discussion focuses on the extensive effects hormones have on overall health, particularly in women, and the common misconception that hormone therapy is inherently dangerous. The risks of stopping hormone therapy after a certain age are examined, challenging the notion that it should be discontinued. Both the physical and mental health implications of hormone therapy are discussed, suggesting that appropriate treatment can greatly enhance quality of life. Encouraging open discussions about hormone therapy can empower women to make informed healthcare choices.
Challenges in Breast Cancer and Hormonal Treatment
Dr. Rubin addresses how familial or personal histories of breast cancer impact hormone therapy options for women. Women with a history of breast cancer may be hesitant to pursue hormone therapy for fear of recurrence, yet the conversation emphasizes individualized treatment plans. The timing hypothesis is questioned, suggesting that age should not dictate the ability to use hormone therapy effectively. This nuanced approach can help determine the best course of treatment based on individual circumstances and preferences.
The Importance of Vaginal Health
The podcast highlights the often overlooked issue of vaginal health, particularly in the context of menopause, where loss of hormonal support can lead to various complications such as urinary tract infections and pain during intercourse. Dr. Rubin discusses the significance of local vaginal hormone treatments, which offer substantial benefits for urinary health and sexual function. These treatments can improve quality of life and prevent complications associated with atrophy in the vaginal tissue. The emphasis on vaginal health and associated therapies supports the need for more comprehensive education and resources for women.
Misconceptions and Marketing Issues
The discussion delves into the marketing challenges surrounding hormone therapy and the misinformation that persists in both healthcare and popular culture. Despite the proven benefits of hormone therapy, many women remain misinformed due to fear-based narratives and a lack of education among providers. The podcast advocates for a shift in understanding that highlights the importance of hormone therapy for female patients, especially concerning preventing chronic diseases. By addressing misconceptions and promoting accurate information, women can better advocate for their health needs.
Role of Testosterone in Women's Health
The overlooked role of testosterone in women’s health is a key theme discussed in the podcast, emphasizing its importance alongside estrogen and progesterone. Dr. Rubin explains that women produce significant amounts of testosterone, which declines with age, affecting libido, mood, and overall well-being. Aside from sexual health benefits, testosterone therapy for women may enhance energy levels and improve mental clarity. This aspect of hormonal therapy highlights the need to consider the full spectrum of hormones rather than focusing solely on estrogen.
Access to Quality Hormonal Treatments
Access to competent hormone therapy providers is crucial for women looking to manage menopausal symptoms effectively. The podcast encourages listeners to seek healthcare providers who prioritize patient education and individualized treatment plans. Resources such as specialized menopause societies and women's health organizations can help connect patients with knowledgeable practitioners. The significance of understanding one's unique health needs cannot be overstated, as it empowers women to make informed choices regarding their hormone therapy.
Rachel Rubin is a board-certified urologist and one of the nation's foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women’s sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women’s Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women.
We discuss:
Rachel’s training in urology and passion for sexual medicine and women’s health [3:00];
Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women’s health and quality of life [5:30];
Why women have such varied responses to the sharp drop in progesterone during the luteal phase and after menopause, and the differing responses to progesterone supplementation [14:45];
The physical and cognitive health risks for postmenopausal women who are not on hormone therapy [17:45];
The history of hormone replacement therapy (HRT), and how misinterpretation of the Women’s Health Initiative study led to abandonment of HRT [20:15];
The medical system’s failure to train doctors in hormone therapy after the WHI study and its lasting impact on menopause care [29:30];
The underappreciated role of testosterone in women’s sexual health, and the systemic and regulatory barriers preventing its broader use in female healthcare [35:00];
The bias against HRT—how institutional resistance is preventing meaningful progress in women’s health [46:30];
How the medical system’s neglect of menopause care has opened the door for unregulated and potentially harmful hormone clinics to take advantage of underserved women [53:30];
The HRT playbook for women part 1: progesterone [57:15];
The HRT playbook for women part 2: estradiol [1:05:00];
Oral formulated estrogen for systemic administration: risks and benefits [1:13:15];
Topical and vaginal estrogen delivery options: benefits and limitations, and how to personalize treatment for each patient [1:17:15];
How to navigate hormone lab testing without getting misled [1:24:15];
The wide-ranging symptoms of menopause—joint pain, brain fog, mood issues, and more [1:31:45];
The evolution of medical terminology and the underrecognized importance of local estrogen therapy for urinary and vaginal health in menopausal women [1:37:45];
The benefits of vaginal estrogen (or DHEA) for preventing UTIs, improving sexual health, and more [1:41:00];
The use of DHEA and testosterone in treating hormone-sensitive genital tissues, and an explanation of what often causes women pain [1:50:15];
Is it too late to start HRT after menopause? [1:56:15];
Should women stop hormone therapy after 10 years? [1:58:15];
How to manage hormone therapy in women with BRCA mutations, DCIS (ductal carcinoma in situ), or a history of breast cancer [2:00:00];
How women can identify good menopause care providers and avoid harmful hormone therapy practices, and why menopause medicine is critical for both women and men [2:06:00]; and
