The Diary of a CEODr Rachel Rubin: "I'm Filled With Rage!" Your Doctor Was Never Taught About Women's Bodies!
CHAPTERS
- 0:00 – 3:25
Vaginal estrogen: the overlooked fix for painful sex and recurrent UTIs
Dr. Rubin opens with a practical demonstration of low-dose vaginal estradiol and why she believes it’s a wildly underused, high-impact treatment. She argues it can relieve dryness and pain, improve arousal and orgasm, and dramatically reduce UTI risk—yet most eligible women aren’t prescribed it.
- •How vaginal estradiol is applied and typical dosing frequency (e.g., twice weekly)
- •Quality-of-life benefits: less dryness, less pain, improved arousal/orgasm
- •Health benefits: UTI prevention and why UTIs can become life-threatening with age
- •Systemic under-prescribing and access barriers despite low cost and generics
- •Her emotional framing: “rage” at preventable suffering due to misinformation
- 3:25 – 7:22
Why women’s hormone and sexual healthcare is failing (even for the rich and famous)
Rubin explains how gaps in medical education and clinical training leave women without informed care on menopause, hormones, and sexual health. She highlights high-profile examples (Oprah, Melinda Gates, Halle Berry) to show that wealth doesn’t protect women from misdiagnosis and dismissal.
- •Women’s health expertise is scarce across specialties; research doesn’t automatically change practice
- •Time-crunched appointments and clinicians avoiding nuance by saying “no”
- •Shared decision-making is common in men’s health but often missing in women’s care
- •Examples of misdiagnosis and delayed/denied hormone therapy even among celebrities
- •Core claim: doctors weren’t trained—so patients must often self-advocate
- 7:22 – 11:30
The clitoris knowledge gap: what OB/GYN training leaves out
Rubin details how basic vulvar/clitoral anatomy is rarely taught, leaving patients without language or understanding of their bodies. She describes her approach of using mirrors during exams to teach anatomy and empower patients in clinical and intimate settings.
- •The word “clitoris” not included in some formal OB/GYN training checklists (per Rubin)
- •How lack of anatomical education fuels shame, confusion, and poor sexual outcomes
- •Mirror-based exams as a tool for education and body literacy
- •Why patients expect OB/GYNs to be sex experts—and why that expectation often fails
- •Empowerment through language, accurate anatomy, and seeking better-informed clinicians
- 11:30 – 12:24
Hormones 101: why women ask about them—and why doctors fear them
The conversation turns to hormones as the most common topic Rubin is asked about, and why misconceptions persist. Rubin frames menopause as a whole-body ‘shutdown’ event and argues that fear of hormones stems from politics and misread science rather than current evidence.
- •Why hormones are treated as “dangerous” despite being fundamental biology
- •Menopause described as a systemic event affecting brain, bone, heart, bladder, and sex
- •How training gaps create strong clinician opinions without strong evidence
- •Key topics patients bring: hormones, pain with sex, libido
- •Reframing care around individualized risk/benefit and shared decision-making
- 12:24 – 17:11
Testosterone in women: the missing piece (and libido impacts of birth control)
Rubin explains that testosterone isn’t just a ‘male hormone’ and that levels in women often drop in their 30s—well before menopause. She links hormonal manipulation (especially combined oral contraceptives) to libido and arousal changes and describes how testosterone therapy is used off-label in carefully adjusted doses.
- •Testosterone decline often starts in the 30s, affecting libido, arousal, orgasm timing, lubrication
- •Birth control mechanism: ovulation suppression lowers endogenous hormone production (including testosterone)
- •Real-world libido changes when stopping birth control and why that may happen biologically
- •Testosterone therapy evidence strongest for libido in postmenopause; emerging for perimenopause
- •Clinical approach: low-dose prescribing, expectations (3–6 months), and not “for everyone”
- 17:11 – 20:31
Medications and libido: antidepressants and GLP-1 weight-loss drugs
Rubin argues that informed consent often fails to include sexual side effects, even when they’re common and relationship-altering. She discusses antidepressants’ known sexual impacts and highlights early, patient-reported signals that GLP-1 medications may affect libido and orgasm for some women.
- •Antidepressants: low libido and delayed orgasm as common trade-offs
- •Informed consent: patients should hear common, uncommon, and severe side effects—including sexual ones
- •GLP-1s (Ozempic/Mounjaro class): limited research on women’s sexual side effects
- •Rubin’s survey findings: a substantial minority report sexual changes (worse for some, better for others)
- •Why sex outcomes should be measured in drug research, not just fertility/pregnancy endpoints
- 20:31 – 25:42
Menstrual cycle fundamentals and why perimenopause starts earlier than you think
Rubin walks through estrogen and progesterone patterns across the cycle, then connects these patterns to life-stage changes. She emphasizes that perimenopause can begin around 35 and may cause wide-ranging symptoms that are often dismissed or misattributed.
- •Cycle basics: low hormones during bleeding, estrogen rise to ovulation, progesterone in luteal phase
- •Hormone ranges: cycle vs pregnancy vs menopause and what ‘replacement’ aims for
- •Perimenopause timeframe framed as ~10 years before menopause; symptoms can start mid-30s
- •Symptom breadth: sleep issues, anxiety, cognition, joint pain, dry eyes, UTIs, sexual pain
- •‘NFLM’ (not feeling like myself) as a common but often-dismissed clinical presentation
- 25:42 – 27:49
HRT explained: what it is, how it works, and the cancer/uterus question
Rubin defines hormone therapy and clarifies why estrogen is commonly paired with progesterone for people with a uterus. She breaks down the anatomy behind endometrial thickening concerns and reframes HRT as a toolbox rather than a one-size-fits-all mandate.
- •HRT/HT definition and the common components: estrogen + progesterone (and sometimes testosterone)
- •Why unopposed systemic estrogen can thicken the endometrium; progesterone provides protection
- •Patient goals: hot flashes, sleep, bone density, mood/cognition, sexual function
- •Different use-cases across reproductive years, postpartum/lactation, perimenopause, and postmenopause
- •Practical emphasis: individualized therapy based on symptoms and objectives
- 27:49 – 29:38
Why HRT got a bad reputation: the Women’s Health Initiative fallout
Rubin recounts how early-2000s messaging about the Women’s Health Initiative (WHI) created widespread fear and a prescribing collapse. She argues the study was misinterpreted in the public narrative, producing a generation of clinicians who were never taught how to prescribe hormones safely and effectively.
- •WHI trial design and age range of participants; early stoppage and headline-driven panic
- •Public claim vs Rubin’s interpretation: risk messaging and nuance lost
- •Downstream consequence: clinicians stopped prescribing and stopped learning how to prescribe
- •Recent reassessments (as Rubin describes) and changing understanding of risk by age/type
- •Current gap: very low proportion of eligible women receiving hormone therapy
- 29:38 – 38:54
The ‘four buckets’ approach: systemic estrogen/progesterone/testosterone + vaginal hormones
Rubin outlines four categories of hormone interventions and focuses on vaginal hormones as a uniquely safe, local therapy. She explains GSM (genitourinary syndrome of menopause), how vaginal hormones support the microbiome and bladder, and why they can prevent recurrent UTIs.
- •Four buckets: systemic estrogen, systemic progesterone, testosterone, and vaginal hormones
- •GSM: hormonal effects on vulva/vagina/bladder leading to dryness, urgency, leakage, pain
- •Vaginal microbiome and acidity: hormones support protective bacteria and reduce infection risk
- •Forms and practicalities: cream, tablet insert, ring, and vaginal DHEA options
- •Cranberry/wiping/peeing-after-sex as limited/folklore vs stronger evidence for vaginal hormones
- 38:54 – 47:27
When to start hormone therapy: symptoms, postpartum ‘menopause,’ and a success story
The discussion shifts to timing—Rubin argues therapy should be guided by symptoms and goals rather than waiting for a strict milestone like 12 months without a period. She uses postpartum/lactation as an example of temporary menopausal-level hormones and shares a patient story illustrating stepwise benefits from vaginal hormones to systemic therapy.
- •Not calendar-based: start when symptoms and patient goals warrant it
- •Postpartum/lactation: steep estrogen crash and sustained low hormones during breastfeeding
- •Common postpartum symptoms: hot flashes, pain with sex, urinary issues, libido changes
- •Stepwise care model: vaginal hormones first, then systemic estrogen/progesterone, then testosterone if needed
- •Case example: improved sleep, UTIs, hot flashes, bone health, libido, and cognitive function
- 47:27 – 50:09
Pain during sex: the diagnostic mindset (skin, muscles, nerves, hormones, endometriosis)
Rubin emphasizes that sex shouldn’t hurt and pain warrants a real diagnosis rather than dismissal. She reviews common physiological sources of pain—skin conditions, pelvic floor muscle issues, nerve/spine referral, and internal scarring—while noting many clinicians lack training in these evaluations.
- •Pain with sex prevalence and why normalization is harmful
- •Differential diagnosis: hormonal tissue changes, dermatologic conditions, muscle hypertonicity, nerve/spine issues
- •Endometriosis and internal scarring as deep pain drivers
- •Action steps: seek specialists in pelvic pain; get second opinions as needed
- •Hormones as a major contributor for many—though not the only cause
- 50:09 – 1:05:20
Better sex framework: pelvic floor, orgasm realities, clitoral adhesions, and sex toys
Rubin reframes ‘great sex’ as a blend of fundamentals (health, safety, communication) plus targeted tools (therapy, hormones, devices). She explains pelvic floor function, why many women don’t orgasm from penetration, introduces clitoral adhesions as a treatable condition, and discusses vibrators as legitimate anatomy-aligned aids.
- •Pelvic floor basics: coordination, relaxation for penetration, contraction patterns for orgasm
- •Orgasm gap and education: clitoral stimulation vs penetration-centered scripts
- •Clitoral anatomy as largely internal erectile tissue; implications for arousal and technique
- •Clitoral adhesions: prevalence (as Rubin states) and office-based treatment improving outcomes
- •Sex toys/vibration as practical tools for arousal, pleasure, and muscle tension relief
- 1:05:20 – 1:33:44
Porn, desire styles, and the communication skills couples avoid
The final stretch addresses how porn can skew expectations, how desire can be spontaneous or responsive, and why couples stop talking once life gets busy. Rubin and Bartlett discuss scheduling intimacy, negotiating mismatched preferences, sharing fantasies safely, and reducing shame by treating sex issues as shared problems rather than personal failures.
- •Porn as male-demand-shaped media; risks include unrealistic scripts and desensitization when hidden/compulsive
- •Healthy vs unhealthy porn use: consent, transparency, and relationship agreements
- •Spontaneous vs responsive desire and why foreplay/context often matters more for women
- •Scheduling intimacy and creating ‘quarterly’ protected couple time to rebuild connection
- •Communication tools: talk outside the bedroom, debrief what worked, use therapy/apps as scaffolding
- 1:33:44 – 1:47:58
Why this work matters: biology + advocacy + practicing what you preach
Rubin closes by stressing that women’s biology is often minimized and that clinicians and partners need to take it seriously. She calls for better training, better access, and more honest conversations—while acknowledging the personal challenge of living the advice she gives patients.
- •Core takeaway: biology matters alongside psychosocial context
- •Partner involvement in exams/education can reduce blame and increase empathy
- •No ‘bad guy’ framing: couples vs the problem, not each other
- •Rubin’s personal reflection on work-life balance and applying her own guidance
- •Where to learn more: website/newsletter, education initiatives, and clinical practice info
