Menopause, Hormones and Women’s Sexual Health with 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 OBGYNs 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 OBGYNs 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 an OBGYN is expected to know about breast cancer and heart disease and bone health. It makes no sense. the views and 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 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 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 for the 2025 American 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, 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 health care. 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. 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. Women in midlife face questions that don't come with easy answers. Conflicting research on hormone therapy, financial decisions, relationship shifts, questions about your own health that require real thought, not just a quick search. Claude is an AI built for that kind of thinking. When you're trying to understand why experts disagree or work through something personal and complicated, Claude doesn't give you a quick answer and move on. It sits in the complexity with you, asks follow-up questions, helps you think through the trade-offs. And Anthropic, the company behind Claude, has committed to keeping Claude ad-free. Claude's responses will not be shaped by advertisers or third parties. When you're making decisions about your life, that integrity matters. Try Claude for free at Claude.ai slash Unpaused to see why problem solvers choose Claude as their thinking partner. Welcome to Unpaused. Oh, my gosh. How cool that we're finally doing this. Oh, my God. You are like people don't know that we actually know each other. So when we're like, who should we have on the podcast? Your name was like at the top. Oh, my gosh. Like they want to talk about sex. They want to talk about sexual health. And I'm like, I'm and here we are doing it. Let's let our audience get to know you a tiny bit. Where are you from? So I'm a little bit from all over. I 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, sexual medicine fellowship in San Diego. So I got to live in San Diego for a year, which is not a terrible place to have your first baby. And I'm practicing in the Washington, D.C. area. Okay. Why urology? It's, you know, for our listeners, most women do not choose urology as a profession. Yeah. Every little girl dreams of being a penis doctor, actually, as part of, you know, a life's dream. It is kind of strange how I got here. Sometimes I wake up, I say, how did I end up here? You know, 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 know, 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 women actually have kidneys and ureters and bladders. Shocking. 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. You did a sexual medicine fellowship, which is rare as well. Yeah. What was that like? 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, totally him on the podcast, this guy, Erwin 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 ISWISH, the International Society for the Study of Women's Sexual Health, I-S-S-W-S-H. 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'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 how to talk to you about libido, arousal, orgasm or pain is no one ever taught them. I learned nothing, like literally nothing. And say it louder for the people in the back, because it's not your fault. Right. 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, you know, infected area or whatever. But, like, so I graduate, and I go into my clinical practice. 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 for gynecology or their well woman in 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. 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 OBGYNs 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 OBGYNs 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 an OBGYN is expected to know about breast cancer and heart disease and bone health. It makes no sense. I absolutely agree. I will. And then the other sad thing is I go out to my, you know, my bosses who were older seasoned, you know, OBGYNs and say, I've got Miss Smith and, you know, what do I say? What do I do? And now that I realized 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 anything but let's address the problem, what's going on. I never learned the framework of addressing sexual dysfunction until I decided to open my menopause clinic. And the magic is time. And I think our current health care 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 listens to you, who can really know, you know, kind of what you want, what your goals are. And there's 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. You don't love your husband. 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 ask if they have a sexual problem. You have a 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 was approached as far as sexual health. I think we've actually been more successful at this because we're coming at this from the outside of OBGYN and saying, wait a minute, we don't do this for men. Everything is 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 have this. You absolutely shouldn't. It's not that 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. at Johns Hopkins and do multiples 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. And what happens on the female side of this? 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. Prove me wrong. 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 not even medically recognized or 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 Kelly and people who were taking her men going, wait a minute, we don't do this to men. We don't castrate men 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 discovered 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 going to 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 is not funding or doesn't research, right? And so the people who fund research, sexual health is going to be the last thing that gets funded. I love that quote of the NIH doesn't care about your orgasm if you're a woman. Even men, they don't particularly care about men. Actually, I will say, and I'll defend it. 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 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 well established. There's certainly things we can do to improve. But the rare conditions, so I take care of a lot of rare male sexual dysfunction, 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 studying it. 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 understand because they are also dismissed by the medical community. 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 bulbo cavernosa, you know, repairing lacerations after delivery. And I was going right through these little legs on her necklace right here. So it's really interesting. I'm obsessed with this concept of a word called homologs. Okay, homologs are this idea that the head of the penis and the head of the clitoris are exactly the same thing. We all form the same. It's the same tissue. 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 cura or to 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 skins 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 menorah. 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 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, 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? And that's why the vibrator industry is many billion dollar industries and probably should be a quadrillion dollar industry. If people understood that it doesn't make you a bad partner, most women are never going to 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 most people orgasm from clitoral stimulation, just like most men orgasm from penis stimulation. Why is it that Hollywood, every woman has a earth shattering orgasm within 14 seconds of penis and vagina. Why is the WWF not real? You know, it's entertainment. How are you going to 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 Dr. 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 so it's really, you know, when women say I'm broken, I can't orgasm from penetration. Well, it's 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 does not last in 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? 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 go wrong in the surgical space because we were never taught really the correct anatomy? Yeah, this is a true disaster. 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 the World 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 surgeries, and 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 neuroinervation. 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 erection. So it's the same anatomy, except the textbooks show the penis one and no one even looks at, no one's even decided to study the clitoris side of things. And so we don't even have that data, right? 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 it was a surgical complication, this was psychological. 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 and 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 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 orgasmed. 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 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, what did you learn in OBGYN residency about cervix inner innervation? Cervix has no nerves. Okay, so everyone hears that, right? OBGYN, very high academic center was taught cervix has no nerves. Yet when you stick the cervix and pinch it for an IUD does not hurt people they scream so there are no nerves that doesn't make any sense and you know after the x amount time you're like this this is hurting her and so the research shows that it's not only innovate 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're stretching, say vagal, right? Which is they get dizzy and nauseated and try to pass out. Which is also cool because this amazing researcher, Barry Kamenzurak, 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 OBGYNs 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? So you treat women who by the time they get to you, because you're like high level specialist, like a woman doesn't think I need to go to a urologist. Right. 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? Absolutely. So, 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 is actually so magical I had a patient come to see me She was 16 years old This was 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. Like, 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 and 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, no, I don't have an appendix. And she was able to wear tampons and she was able to have. And she couldn't wear tampons because of pain. She couldn't wear tampons because of pain. So I'm sure someone's out there going ding, ding, ding, listening. Okay. What is a vestibulectomy? Where is the vestibule? Yeah. So let's go back. So if, okay, pain is not, you should never have pain. Okay. Let's be clear. Say that louder for the people listening in the back. You should never have pain. Yeah, it shouldn't hurt. Ever. Yeah, it shouldn't hurt. Sex shouldn't hurt. Penetration shouldn't hurt. Speculum 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 should not get a diagnosis of you're stressed or, oh, the doctor, 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. We'll talk about that. You may have a muscle problem because your pelvis is just surrounded by big, bulking muscles. Let's go there. Why would a woman have pain in this area? It's such a small area. 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. 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 fire, 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, it 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 vulvar vestibule tissue, right, the labia, our skin, it's tough. They can take a beating. They can take a jalapeno pepper. 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 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. Where would you find those videos? 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. Tossing and turning all night and waking up sore doesn't mean you're a bad sleeper. It probably means you're sleeping on the wrong pillow. That's where Coop Sleep Goods come in. Coop makes adjustable sleep essentials designed to move and support exactly how you sleep. Side sleeper, back sleeper, stomach sleeper, or somewhere in between. Coop pillows can be customized by adding or removing fill until it's just right. No one size fits all here. Coop delivers personalized prescription strength rest without the prescription. Better sleep doesn't just change your nights. It changes your days. more energy, sharper focus, greater clarity. When you sleep better, everything else falls into place. It's time to stop settling for restless nights. Sleep better, wake up stronger. Take on your day fully charged, focused, and ready for anything. Let Coop help you show up feeling rejuvenated and ready to go. Get 20% off your first order and try Coop risk-free with 100-night sleep better guarantee at coopsleepgoods.com forward slash unpaused. That's C-O-O-P sleepgoods.com slash unpaused. Okay, so you have skin issues. So that caused pain. And you mentioned muscle. Yep. So what is that like? 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? Like these muscles and there are superficial ones and there are 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 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 treat men, they treat women, they treat every day, you know, and 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. Amazing. What are the like common misdiagnoses that you see after women finally make their way to your office? 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. Truly, I'm 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 reach their goals and give them a toolbox that then they 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 many 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 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. That's 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. They're like, well, surely this is in my head because I've seen 10 doctors. And that's the magic, right? Have they been told that everything looks 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 therapist 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, OK, 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 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. 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? Because this idea of like, I hear a story and then you come up with a hypothesis. Then you start thinking, 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, can the biology make sense here? And I'm curious. And then because of social media, I have all these new 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 that your whole body is being affected and we need to look at all of you and treat the problem that you came in with. So let's move on to genital urinary syndrome of low estrogen. I hate calling it of menopause, but 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. And I would clarify, and this is actually the problem. So the name of this condition that used to be terrible, well, Atrophic vaginitis? Well, even senile vagina. Senile vagina was my favorite, right? There was a paper long ago, senile vagina, which then became atrophic vaginitis, which is not very nice, or vulvovaginitis. 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 happen 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, right? So let's break it down. How does low estrogen states cause the urinary symptoms? Yeah. And one clarification is it's not just estrogen. And the guidelines that we put together, the American Urologic 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 OBGYNs 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. 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. But again, it's not about menopause. It's about androgens dropping in your 30s. And so the genital tissue is androgen and estrogen driven. And so what's happening... So by androgens for our listeners, you're... Testosterone. 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. 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. 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 it 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 gonna 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 genital urinary syndrome of menopause is a little bit not good because it's not menopause. It's perimenopause. It's breastfeeding. It's 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. So in GSM, we have urinary symptoms, you mentioned arousal and orgasm. So talk about those in this low hormone state. 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 genitals literally blossom, right? You grow labia, they get bigger, your 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 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 you and I broke the internet this year because we talked about... In reference to that viral video where you talked about the loss of the labia. 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. But it's not just the labia that changed. The clitoris gets smaller. Talk about that. We lose the volume of the clitoris. 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 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? 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 you need hormones to help 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 slipperier, 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. You know, the old guidelines said, you don't start, you don't replace the hormones or consider hormone treatment until they fail lubricants. 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 as moisturizers and lubricants, because moisturizers and lubricants do not prevent urinary tract infections. Urinary tract infections kill your grandmother. They kill your mother. They kill the people that you love. And we should be preventing them with every fiber of our beings. How much can we prevent with vaginal estrogen? More than half, more than half. And it's probably higher than that, but the data is more than half in most studies. It's wild. 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 and urosepsis. I'm so excited to do this, right? Because every nursing home director has a huge problem with urinary tract infections because when little old ladies get urinary tract infections, they get delirious. They fall. They break their hips. It is costing our health care system so much money. So we published this year or not this year in 2024, if we gave women in Medicare vaginal estrogen 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 six and twenty two billion dollars a year. And I think it's a conservative estimate, which is insane. Right. And so it should be talked about. But I always joke and I wish this is 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. Also, 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 new GLP peptide. It's a little insert you put, you know, you just place it vaginally, but it's your bladder microbiome support. 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 body. 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 in humans, 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 one 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, our 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 friends, I need you to do this. I need you to get your hands, roll up your sleeves, write the prescriptions and you will save lives. Talk to me about DHEA and the differences, you know, how is that different and the vaginal DHEA and would you consider systemic DHEA? 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. It is the darling of the wellness world. And I'm not here to just like, I think I need more data. Yeah, 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 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 aromatase 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. It's 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 it 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 hell in that organization to get these products sort of approved for veterans. A lot of pushback in our older patients who aren't comfortable touching their vaginas, who, you know, and especially nursing staff. So in 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 ospemophene, would you think that this... 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 suppositor? Because locally, it 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. Ospemaphene 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, the worry is that you increase a risk for something like a blood clot. And so putting a woman who's 90 in the nursing home with 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, you know, a vaginal bladder problem and not cause any side effects. 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 guessed 30 to 40 percent of women were on some form of systemic HRT, and that dropped to almost nothing. So as of two years ago, FDA-approved formulations were at about 4%. 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 and 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 know what to do. They're going to treat the symptoms, throw an SSRI at them, but there are sexual side effects as well. Yeah. And it's funny because no one seems to disagree that there are sexual side effects of antidepressants. There are sexual side effects. 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 People who can orgasm All we were taught was sexual side effects We did not quantify Okay well we quantify it Okay fine So yeah So okay Medicine can have sexual side effects right That 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 tools in our toolbox to help with this problem. And the challenge is, 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 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 could add? 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 be genital numbness or, you know, anhedonia. Yeah, let's talk about those because it's, there's a libido issue potentially, and then there's also arousal and orgasm issues. So let's break those down because the listeners are like, whoa. Yeah, no, and there are some that really don't get talked about. So 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 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 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 sex education is really bad in 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, they don't have the language. And so you have to teach them their bodies and their anatomy to even find out sort of where the problems might be. And so medications can cause sexual side effects. OK, mental health issues can cause sexual side effects. Bad relationships can cause sexual side effects. A partner ectomy, 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 is biopsychosocial? And I think too often we jump to that. 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 a mental health specialist. 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. It's a great question. So again, let's go back to this. Your OBGYN, who's responsible for delivering babies all night long, emergency surgeries, massive blood transfusions, women dying in childbirth, dead babies. All the things. 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 is 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. It's 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 OBGYN sort of training. So you all... But we know that there's one. So, yes. We kind of know that top part. But if you look at CRIOG, which is sort of your check marks of what I must know to graduate as 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 that. 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 that. 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 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? They saw an economic opportunity. 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 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 your orgasm breaks down, who do you go see? Who takes care of you? Who can you even talk to about it? So one other drug I want to cover as far as sexual side effects. And this, you know, I feel like we have to tread lightly because this is like a hot topic political. Anytime we mention 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 that have side effects. Walk me through, because 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 suppressing ovulation. Yeah, so the data is mixed here, I would say. and I would love to see more data on it. But 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 turn off your ovaries, which is elegant, right? So you don't ovulate, you don't ovulate, you don't have a baby. Well, you're winning. 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 a final 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 and 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, they have pain with sex, said, Oh, I was fine until I started my birth control pill. And then everything went south. And so that for those patients, we get their story, we talked to them, we examined 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 a contraception for these patients who are prone. And not every patient that takes birth control has these side effects, but those 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 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 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. This could be a possibility. I didn't even know that my birth control was 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, 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 medical legally, like, I think those patients sue less because they feel like they were informed and a part of the decision-making process. Right. 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? 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 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 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 changes. 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, Saul Palmetto is one 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 this episode of unpaused is proudly sponsored by amica insurance it feels good to be understood amica goes above and beyond to customize the right coverage for you by taking the time to really understand your needs because putting you first is what a mutual company does. 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That's M-C-H-2-0 for 20 bucks off your first order. Your personalized skincare ships right to your door. No appointments, no pharmacy lines. Because your skin's changing and your routine should too. Visit myalloy.com and use code MCH20. That's MCH20. So one more drug and 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 GLP-1 use and sexual function. Did you read it? 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 GLP-1 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 GLP-1s. 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 are just like slow gastric emptying or nausea or side effects. Sexual side effects may be happening. And 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 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 conversation 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. We have two FDA approved drugs for low libido and premenopausal women. OK, they work great in postmenopausal women. and we use them frequently. And the data is very clear. They work in postmenopausal women. Yeah, I think that paper's coming out soon. So the two medications is, the first one is Addy 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. For our listeners, if they don't know, Let's talk about getting Viagra through the FDA versus getting Addy through the FDA. There's two drugs for FDA approved for low libido. So Addy, which is flibanserin, and Vilisi, which is breamilinatide. One is a pill you take every day. Works kind of like it works on your brain. So it boosts dopamine in your brain. You take it every night. Similar to Welbutrin, 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 two to three months to know if it's working for you. My patients say, oh, my God, my sex dreams are back. Like, 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 medications. It's like any other- Like give it a try. Right. If you are comfortable with Lexapro or Welbutrin or any drug like that, Addy is very no different from the side effect profile. So the other drug is Vileci. 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 it's not just libido. It's arousal. It's orgasm. It's sort of all of these domains. And Addy is too. So if you look at Addy, 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 you must see this documentary, we're hoping it gets a U.S. distributor, but you can do private viewing. So if you go to pinkpillfilm.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 the cancer drugs go on this level because that's how important it was to get an erection drug approved by the FDA. Labanserin, 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, oh, 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, it was only 10 years ago. I was there. And in Viagra, it was like, well, he might have a heart attack, but he has an erect. He could go blind. He could go blind. So there is one point in the movie. This is amazing. while they were trying to get this drug approved. And again, this drug works. And 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 1,000 men. It's for penile curvature. And the side effect is penile rupture. So your penis can 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 on 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 was what the small community that tried to get it through, it truly explains women's health in sort of a 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. Nothing can affect your ability to have a baby, right? That is your fertility is the most important thing. 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 Addy approved. I have never been told by a man's sexual health medicine, well, we will not approve that unless they fail marriage counseling. You have to get a divorce from Blue Cross to care about it. 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. It actually is. And we're just not using what we have because no one's even like having those conversations. 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 and 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 as like, I don't feel like myself. Now, this is a woman who was previously feeling like herself, previously functional, had her stresses, had her marriage, had her kids, had 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? 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 I give women back hormones in their body in an 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 chest. It's not right away. It takes about four to six months of testosterone. I told the 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'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 our 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 decision making, tinkering, trying things out, figuring out what 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 phlebancerin or a bremelanotide for libido? Is it an antidepressant to help with anxiety and mood? Is it GLP-1, right? We're seeing a lot of interest in GLP-1s. And I think 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, 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 in 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 me. Dr. Carcinoma in situ, so stage zero breast cancer. Yeah. So she was a breast cancer patient. She actually came to me years ago and said, I want hormone therapy. I was like, oh my God, you have breast cancer. I don't know. Here's the data. Here's what we know. Here's what we 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, listen I already at a high risk for a recurrence If it happens we deal with it I am like suffering from perimenopause So we ultimately made a shared decision situation She started estrogen and progesterone She did great for 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 reel because I'm talking about her and she's in the background talking too. And she was excited to make that reel. She was excited to tell people about it, right? Of this idea of like, well, I want other women to experience what 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. Where does testosterone matter most in this like cascade? because, you know, female sexual function is, 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? I think there's local topical testosterone, like your vaginal DHEAs that can help with the bladder and the urinary symptoms. Is there a vaginal testosterone formula? 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 area of research. In postmenopausal patients. Yeah, like when it's very rare that people actually study a woman who's postmenopausal. 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. They want to age with dignity. Yeah. It's so simple. 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 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 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. 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 like crypto, right? So like I think of like, 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 savings. It's like your high-yield savings account. Everyone should have one, have an emergency fund. Those are things you should do. I think hormones might be like your investment portfolio. It might be your 401k of like, and it's okay. As you're thinking of diversify, diversify your portfolio. So care about your nutrition, care about your connection to people, care about your mental health, care about your sexual health. 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 is risky. Right. And that's what I think all of this conversation could be. So doctors need to do a better job. We're not perfect. You guys were human. We have egos. We have lives. We're busy. We're not trained on this 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. 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? This is the challenge of podcasts and more importantly, Instagram, right? This 90-second reel is not necessarily going to answer your specific question. 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 Kasperson. You want to get it for 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 going to 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 going to 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 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 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 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 a patient to know what your toolbox is. 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 and 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 have a foot in both worlds, male and female medicine, why do you think that there's this double standard? It's research and science. I mean, it's that we haven't valued. 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 to go into 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, we have 27 products 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 homologues. 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 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. How does this show up in insurance? Oh, my God. Don't even get me started. Right. Started. When I left fellowship. Right. It became, oh, I couldn't get hired, Mary Claire. Like I couldn't get a job. The academic center said what you do is weird and you will not make us enough money fast enough. The private equity. That's why I had to leave the academic institution to go do menopause care. You will not make enough talking to patients. 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 spend time with people. us in 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 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. And insurance companies, And insurance, you know, 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 patient is a procedure. And like OBGYNs make money delivering babies and doing surgeries and procedures. Like your role woman exam pays $30 to the doctor. 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 have 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 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? They're paying for men. Not as they are. Yes. Yes. But even that can actually know. And it's right. It's actually limited to. In fact, I wish again, I wish I could say, Ben, have it all easier. Urologists 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 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 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 on women's health. But it's far less than the cardiology research or the orthopedic research or, you know, the sexual medicine urologists like we're still kind of low in the pecking order than like your cancer doctors and like your your reconstructive doctors and things like that. Sorry, friends. I know, you know, they're not listening anyway. It's OK. What is exciting you most about the future when innovations? I am just excited to be alive in 2020. Like I can't believe this year has happened. Right. Like 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 dream. couldn't have dreamt something like that, to be able to help with the guidelines for genitourinary syndrome of menopause. 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. Okay. So 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 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. Like cyanide. We can talk about the risks and the benefits and who should use it and who shouldn't use it. And the nuance is, 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 on 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 Menopause Society asked in 2014, the FDA took two years to respond and just said, no, 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 policy, there's bureaucracy, all of this stuff. And when we left that meeting in 2024, the public person at the FDA whispered in our ears, she's an amazing woman, she whispered to 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. We needed everybody. And we got loud and we did advocacy and we had petitions and we got people. We talked to our legislative people. We just got loud. The journalists got 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 labeling do not make sense. And we're removing them. And so, again, testosterone had a warning label for meds. OK, this is important. Testosterone had a warning label put on. And the warning label, yeah, it caused stroke, blood clots, cardiovascular disease problems. There was an advisory panel to put the label on. So people 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 months or 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. Fine. The label 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. They didn't remove the information. The data is still there. Right. The relative risk and the absolute risk. And it's all still in the label. Read the label, people. Once they update it, it's all still there. And so people getting them, 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 OBGYN. 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, oh, 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, 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. What is one step that she can take tomorrow to begin reclaiming her sexual? 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? 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 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 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. 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 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 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 got to find joy. And if 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 people in your medical team that can help and really support you. Where's the best place for them to start to look, to find a sexual medicine expert or someone that can help them? Yeah, I am very biased here. I love ISWISH, I-S-S-W-S-H dot org. You can find a provider. They have a patient-facing website called ProSela, 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 do. 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 this 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? It is off the chain and all the little like fun little things that you get to take home, clitorises and vibrators. I mean, they're throwing vibrators at you. It's kind of amazing. It's not a bad day when that happens. So if I gave you a billion dollars and said, what are we going to study? So my dream, I have a lot of dreams, but my dream is really to... Someone gave you a blank check. Make your perfect study. So 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 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 physiological. I want a sex lab. I want an orgasm lab. I want to put people, hook up with people up to wires. I want to understand the science. I want to do brain scans. 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 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 to be surrounded by smart people who can ask interesting questions. We're never going to have an institute at the NIH for sexual health. But I'm in Washington, D.C., so can I create like a little one? Can I do 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 quickly. Even from basic anatomy things, we're learning new things every day. 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 of 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 to have you back. Oh, thanks for having me. You can find Dr. Rubin on Instagram and YouTube at Dr. Rachel Rubin 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 or anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness and navigating midlife at thepawselife.com. My new upcoming book, The New Perimenopause, is available for preorder 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 Haver. The views and 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 materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.