Menopause, Hormones and Women’s Sexual Health with Dr. Rachel Rubin

Dr. Rubin emphasizes that this is a life-saving intervention, citing a 2024 study showing that prophylactic vaginal estrogen for Medicare women could save between $6 and $22 billion annually by preventing UTIs, delirium, and hip fractures. She notes that ICU doctors and nursing home directors struggle with recurrent UTIs in elderly women, yet vaginal estrogen is rarely considered due to stigma around the words 'vagina' and 'estrogen.' She jokes that it should be rebranded as a 'GLP-12 peptide' or 'bladder microbiome support' to overcome this. The AUA guidelines now recommend vaginal hormones as first-line, not after failing lubricants, because lubricants only reduce pain from 8/10 to 4/10 and do not prevent UTIs.

Dr. Rubin notes that they published data showing vaginal DHEA prevents UTIs and helps with pain during sex. She mentions that for women on aromatase inhibitors (which block estrogen), DHEA can still provide androgen benefits. She also shares that switching from vaginal estrogen to DHEA can improve urinary urgency in some patients. The challenge is getting it covered by insurance; she fought successfully to get it on the Veterans Administration formulary.

Dr. Rubin teaches this framework in her course for clinicians. She emphasizes that doctors should ask themselves 'What are you afraid of?' when hesitating to prescribe—fear of stroke, blood clots, dementia, or simply not knowing how to manage the patient. She uses an investment portfolio analogy: exercise and nutrition are like a high-yield savings account (everyone should have), hormones are like a 401(k) (diversify), and peptides are like crypto (risky). She stresses that transdermal estrogen does not carry the same blood clot risk as oral, and that for women with osteopenia, the bone benefits of estrogen may outweigh other concerns. The goal is to give patients the full menu and let them choose.

Dr. Rubin points out the absurdity that after a knee replacement, rehab is expected, but after childbirth—where a 'watermelon' passes through the pelvic floor—rehab is rarely offered. She notes that stress, endometriosis, and other conditions can cause these muscles to tighten, leading to symptoms like urinary frequency, pain with sex, and constipation. Pelvic floor physical therapists are 'musculoskeletal colleagues' who can diagnose and treat these issues. She often combines this with local hormone therapy and sex therapy for a biopsychosocial approach.

Dr. Rubin describes Addyi as a tool that works like a 'good night's sleep' and brings back sex dreams. She notes it's been out for 10 years with no major safety issues, and its side effect profile is similar to other psychiatric medications. However, due to the FDA's historical resistance and lack of physician training, it remains underprescribed. She highlights the absurdity of insurance requiring women to fail marriage counseling, a barrier never applied to men's sexual health drugs.

Dr. Rubin explains that Vyleesi is an auto-injector similar to Ozempic, providing an on-demand 'giant hit of dopamine.' She and colleagues are publishing a paper showing it improves not just libido but also arousal, orgasm, and lubrication. She contrasts the ease with which men can access sexual health clinics (even storefronts) with the invisibility of these options for women. She stresses that these drugs are not for everyone but should be part of the informed toolbox.

Dr. Rubin argues that the clitoris is not just the small external nub but a large internal organ with a shaft and two legs (crura) that extend to the butt bones, exactly like the penis. The vulvar vestibule, a thin strip of tissue surrounding the urethral opening, is actually bladder-derived tissue that is highly sensitive to hormones. This tissue is the source of pain for many women with GSM, tampon use, or sexual intercourse. Because doctors are never taught to examine it, they miss the diagnosis. She describes how she uses a mirror in clinic to show patients their own anatomy, pointing out each structure and touching the painful areas, which often leads to an emotional breakthrough where the patient finally believes her pain is real after years of being told everything looks normal. This lack of anatomical education also means that surgeries like hysterectomy, pelvic procedures, or even hip replacements may damage clitoral nerves or arousal pathways without anyone studying or warning patients. She cites the New York Times article 'Half the world has a clitoris. Why don't doctors study it?' as a turning point in public awareness.

Dr. Rubin recounts that after the WHI press conference, the FDA simply added the black box without convening experts. For 20 years, this label deterred doctors and patients. In contrast, when a similar warning was placed on testosterone for men, an advisory panel required a specific five-year study (the Traverse Trial); once that study was completed, the label was removed quickly and without controversy. For estrogen, no such study was demanded, and the label persisted due to inertia. In 2024, after advocacy from medical societies, the FDA hinted that public pressure was needed. Dr. Rubin and others launched a loud campaign involving Congress, petitions, and media. In 2025, FDA Commissioner Dr. Marty Makary publicly stated the labels didn't make sense and they were removed. She emphasizes that the risk information is still in the label, but the black box—which signals life-threatening harm—is gone, allowing nuanced discussions.

Dr. Rubin references the documentary 'The Little Pink Pill' which chronicles the saga. While Addyi was being blocked, the FDA approved a drug for penile curvature (Peyronie's disease) that had a side effect of penile rupture—a far more serious risk—yet it was deemed acceptable because it reduced curvature from 30° to 20°. She argues that the FDA's risk tolerance is vastly different for men's versus women's sexual health. Addyi eventually was approved on the third attempt, but only after intense advocacy. Even today, insurance companies often require women to fail marriage counseling before covering Addyi, a requirement never imposed for men's sexual health drugs. This double standard reflects a broader cultural minimization of female sexual pleasure.

Dr. Rubin explains that women often come in saying they used to handle stress, family, and work, but suddenly feel unable to cope. This is not depression or anxiety alone but a hormonal shift. When she prescribes evidence-based hormone therapy, the most common feedback is 'I feel like myself again.' She shares multiple patient stories: a neighbor who, after five months on testosterone, quit her toxic job to start her own business; a DCIS breast cancer survivor who finally added testosterone after years of hesitation and said 'I am finally back to me'; and many others who simply ask for refills with gratitude. She emphasizes that the goal is not to make women feel like someone else but to restore their sense of self. This approach requires tinkering and shared decision-making, as not every regimen works for everyone.

Dr. Rubin explains that the genital tissues—clitoris, vestibule, bladder—are rich in both estrogen and androgen receptors. Testosterone is crucial for lubrication, arousal, and maintaining the structure of the clitoris and labia. When testosterone drops, women may experience recurrent UTIs, vaginal infections, pain with sex, and decreased libido. This can happen during perimenopause, while breastfeeding, or even on birth control pills, which suppress ovarian testosterone production without replacing it. She notes that the labia minora can resorb and the clitoris can shrink, changes that are visible if doctors look. She wants to study whether it's estrogen, testosterone, or both that drive these changes, but research is lacking. The AUA guidelines she helped write now include the word 'androgen' throughout, acknowledging this broader hormonal picture.

Dr. Rubin walks through several drug classes. SSRIs can cause delayed orgasm, low libido, and genital numbness. Birth control pills suppress ovarian testosterone, potentially leading to low libido and vestibulodynia; she has seen patients whose pain started with the pill and resolved after switching to a hormonal IUD or adding local hormones. Spironolactone and finasteride, used for acne and hair loss, block androgens and can dry out vaginal tissues, causing pain. Accutane similarly dries everything. GLP-1 agonists like Ozempic: her survey found about 10-15% of users report sexual side effects—some positive (feeling better in their body), but many report complete loss of interest in sex. She stresses that this is not a reason to avoid these medications but a call for informed consent and shared decision-making, so patients can weigh what matters most to them.