The Mel Robbins PodcastThe Ultimate Guide to Women’s Sexual Health, Hormone Replacement Therapy (HRT) & Menopause
EVERY SPOKEN WORD
120 min read · 24,390 words- 0:00 – 3:35
Meet the Guest
- MRMel Robbins
Our medical expert today is gonna teach you what every woman should know about menopause, HRT, vaginal health, pelvic floor issues, and the very common hormonal changes that happen to women throughout their lifetime. I truly hope you share this with every woman you know. It will not only change her life, what she learns in this episode might just save it.
- RRDr. Rachel Rubin
People who are on birth control pills, people who are breastfeeding, people who are on hormone therapies and breast cancers, perimenopause and menopause can increase your risk of UTIs drastically. Using vaginal hormones prevent urinary tract infections by more than half.
- MRMel Robbins
Wait, you can get UTIs from hormone changes?
- RRDr. Rachel Rubin
Yes.
- MRMel Robbins
Oh my Go- I've never heard this before.
- RRDr. Rachel Rubin
The biggest PSA that we need is to get this in the ears of every human on Earth, because women are dying. You and your family members are at risk of dying or being in the hospital, and it can be treated for every aged person, for every person with every medical problem, and can cost you as little as $7 a month.
- MRMel Robbins
What? Hold on a second.
- RRDr. Rachel Rubin
All I'm doing here is taking a problem that we have always known about with science that we have always had, and saying every woman on Earth needs to know about this.
- MRMel Robbins
Dr. Rachel Rubin is a board-certified urologist and one of the nation's foremost experts in sexual health.
- RRDr. Rachel Rubin
23% of all women who come into the clinic have what's called clitoral adhesions.
- MRMel Robbins
What is that?
- RRDr. Rachel Rubin
Okay. So I had a woman in my office just this week, and what caused her urinary pain? Birth control pills and spironolactone for her acne.
- MRMel Robbins
My mouth is on the floor right now. I have two daughters in their 20s. Dr. Rubin, if you could speak directly to the person that's listening, if they take one action, what would that one thing that's the most important thing to do be?
- RRDr. Rachel Rubin
I think...
- MRMel Robbins
Dr. Rachel Rubin, welcome to The Mel Robbins Podcast.
- RRDr. Rachel Rubin
Oh my gosh, I'm so happy to be here. This is a dream come true.
- MRMel Robbins
Well, it's a dream come true for me too, and by the time you're done listening, I know you're gonna say to yourself, "Wow, Dr. Rubin is a dream and a treasure. I'm so happy that I chose to spend time listening to this." How might our life be different, or the lives of the women that we love be different if we take to heart everything that you're about to teach us today about hormones, women's sexual health, just the whole range of topics we're gonna cover, much of which you will have never heard in your life before?
- RRDr. Rachel Rubin
Whether you are going through puberty, whether you are going through childbirth, perimenopause, menopause, this is important for your quality of life, your general health, your sexual health, and listening to us today is going to give you the strength and the confidence to learn more and to advocate for yourself so that you live your best damn life.
- MRMel Robbins
Oh, I'm here for it. Your best damn life. Let's go, Dr. Rubin.
- RRDr. Rachel Rubin
My mission is fully that I believe when you give women information about how their bodies work, they make excellent healthcare decisions for themselves. And I truly believe when they have good health, good mental health, good community, good support, they are masterful at f- optimizing their own lives to whatever degree that they want them to.
- MRMel Robbins
So Dr. Rubin, we're gonna cover so much, but I think where I wanna start is what is a sexual medicine doctor
- 3:35 – 5:45
Why Women’s Sexual Health Falls Through The Cracks
- MRMel Robbins
versus a urologist?
- RRDr. Rachel Rubin
Yeah, it's a great question. So urologists are genitourinary doctors, so we take care of kidneys, and bladders, and prostates, and penises, but we also take care of urethras and vulvas. Like, we are sexual medicine doctors first and foremost, but we're surgeons as well, so prostate cancer, bladder cancer, kidney stones, which I've had and don't recommend. So this idea that gynecologists are for women, urologists are for men, doesn't make any sense, because urologists take care of bladders, and last time I checked, most people have bladders, right? It doesn't matter if you're a man or a woman, you have a bladder. You can make kidney stones. You have kidneys. You have genitals. And so we think that our gynecologist should know everything about sexual health, but we don't teach them anything about sexual health. We teach them about reproductive health. We teach them about gynecologic cancers. We teach them about gynecology, which has never included sexual medicine, unless people have taken an extra interest in it. In urology also, we deal with men's sexual health. Think Viagra. Think, you know, erections. Like, that's, uh, how we deal with testosterone for men. We do a lot of this in urology. But women's sexual health has also been historically ignored.
- MRMel Robbins
I... This is brand-new information to me. I'm, like, almost embarrassed to admit it. I, I literally think primary care, gynecologist, primary care, gynecologist.
- RRDr. Rachel Rubin
And that's what I find every day when I talk to patients, is it never comes up.
- MRMel Robbins
Yes.
- RRDr. Rachel Rubin
No one has ever asked me about my sexual health. It's never brought up. And so if you have a problem, if you have an issue, where do you go? The obvious choice is, "Let me go to my primary care. Let me go to my gynecologist," but it's not within their curriculum or what they have to learn about. We have to learn about so many things. The word clitoris doesn't appear in what a gynecologist needs to know to graduate her training.
- MRMel Robbins
Today?
- RRDr. Rachel Rubin
Today, in 2026. So it's not like, oh, I have a bad doctor. No one taught them, so how are they supposed to give you good advice? Now, I wish... My dream, I have many dreams, but one of my dreams is that they actually say, "I don't know. I didn't learn this." Instead, they so often will say something wrong or untrue, or make the patient feel like it's all in their head.
- 5:45 – 6:23
The Most Common (And Harmful) Advice Women Hear About Pain
- MRMel Robbins
W- what are the things that a lot of doctors say to women in particular that aren't true or they're wrong in this-category of sexual health
- RRDr. Rachel Rubin
Oh, drink a glass of wine if you have low libido or have pain with sex. Read Fifty Shades of Grey. Uh, if you have pain with sex, just have more of it. Oh, this is just about getting older. Oh, that part of your life is over now, so you should find other things to do. Every single day, people come to my clinic with stories of how they've been dismissed, gaslit, uh, told they didn't have anything wrong with them, told them they couldn't see the problem, so it must be all in their head.
- MRMel Robbins
What are
- 6:23 – 8:17
The Symptoms Women Are Told To “Just Live With”: Dryness, Painful Sex, UTIs, Night Peeing, Anxiety, Mood Shifts
- MRMel Robbins
some of the symptoms that I'd love for you to normalize that you hear day in and day out so that we all just know the things that you're dealing with, it's not just you, and these are things that you can either make better or that you can get help for or you don't have to live with?
- RRDr. Rachel Rubin
Um, any time you find yourself thinking or even telling yourself, "Oh, this is just how it is getting older."
- MRMel Robbins
Mm.
- RRDr. Rachel Rubin
"Oh, this is just how it is. Oh, my mother went through this. Oh, my friends all have this." Right? How many times do you say, "Ugh, I just don't feel like myself," or, "Oh, I'm just a little stressed," or, "Oh, my mood, I'm, you know, I'm anxious because of X, Y, or Z"? Well, we've all had stressful situations, but is it worse than it used to be? Um, do you find yourself waking up at more at night to urinate? Do you find that sex is a little drier, scratchier, or more painful? Do you find that your orgasm is either gone missing or takes much longer to have? Do you find that you just don't feel like yourself? These are all things that have a biological basis, that if you see someone who is knowledgeable about it can help guide you through this biological basis and give you some biological solutions. Now, that's not to discount our wonderful friends in the mental health spaces, because psychosocial issues affect all of us. I am here to say the biology is also extremely important, and we never talk about it. Low libido is a medical condition if you are bothered by it, and we have medical FDA-approved solutions in our toolbox that work miraculously for people. And so it is so important that we talk to people about these issues so that they don't leak on themselves when they cough, laugh, or sneeze, that they don't get their tenth UTI without asking, "Hey, can I actually prevent this from happening?" Where they see the right clinician, because just because it's someone you've worked with for twenty years doesn't mean they're up to date on what's going on with you now.
- 8:17 – 14:36
Hormones Across The Female Lifespan: Puberty, Ovulation, Pregnancy, Postpartum, Breastfeeding, Perimenopause, Menopause
- MRMel Robbins
Dr. Rubin, why-- can you just give us a brief overview of hormones and what every woman needs to know? And I'd love for you to kind of go in the chunks of what does every twenty-year-old woman, whether she's sexually active or not, in that day, decade? What do you need to know during pregnancy? What do you need to know during perimenopause, menopause, and beyond?
- RRDr. Rachel Rubin
So hormones are not good or bad, right or wrong. They shouldn't come with emotions and feelings and stigma, okay? They just are. They are, and we're learning more about them every day, and we have so much we have yet to know. But let's take it as what, what do we know today? Well, we know that the ovary makes estrogen, progesterone, and testosterone, and we know there's a cyclical way that it is form- like, made. So kids have no horm- sex hormones in their body, or not significant amounts, and then puberty starts, and their gonads start to produce hormones. Their ovaries or their testicles start to produce all these hormones. The testicles produce testosterone predominantly, but boys do make estrogen, right? Men's estrogens are not, uh, are twenty-five. They're not insignificant, which helps their bones. And girls, right, when they have in this, in this, um, uh, pubertal stage, the ovaries are doing these wild fluctuations, and they are unpredictable. And I love talking about perimenopause be- in the way of puberty because we understand puberty. We talk about it. We hold space for it. We don't let teenagers make serious decisions, right? We, we hold space for it. And so the, what's happening is estrogen goes up, progester- if you ovulate, the shell of the egg makes progesterone. Throughout the cycle, testosterone is made. We think it peaks during ovulation 'cause that's what gets your libido going, makes you want to make a baby. And so that's fluctuating, and sometimes it stabilizes. If you're lucky, you get, um, you get, uh, regular irregularity. So it means every twenty-eight days, you're kind of used to this weird twenty-eight-day cycle, but you're irregular, right? The first half, when you have your period, your estrogen is low. It's not zero. It's about fifty, right? Then that, so you're bleeding. You're at your low. Then it goes higher and higher, and it starts to peak at ovulation, and your estrogen might get to one-fifty, maybe three-hundred. You pop out an egg, the shell makes progesterone, and the second half of your cycle, you've got progesterone in your body. And when that egg doesn't fertilize, the progesterone drops. And when it drops, that's what sheds your lining. You get your period. You start all over again. So you are regularly having these irregular sort of shifts of estrogen in the first half, estrogen and progesterone in the second half. When you are pregnant, your estrogen is three thousand, okay? An estrogen of three thousand for about nine months, and then as soon as you have the baby, that three thousand crashes to zero, okay? Crashes to zero, and that's brief menopause. So if you-- and while you are breastfeeding, you are in menopause often that whole time. Sometimes your periods come back, and you start to fluctuate again. But if you are one of those people who breastfeeds and never gets their period back, you are menopausal until you get your periods back, and that comes with every symptom of menopause. The more you understand your hormones and where in your life cycle you are, the more your symptoms start to make sense. "Oh, I'm breastfeeding, and I'm having hot flashes all the time. My sleep is really disrupted. Yes, the baby's crying, but I, my brain fog." Nobody remembers their birth, you know, because you have so much brain fog because your estrogen just went from three thousand to zero. And so the symptoms, the vaginal symptoms, the genital symptoms, the dryness, the irritation, the leakage that's worse, the frequency, the urgency, and the UTIs. And then guess what? Around thirty-five, okay? Around your thirties, your testosterone starts to drop precipitously. Okay, so your t- it's not actually about menopause. It's about age. As we get older, our testosterone starts to drop. Or if you've done something before then to mess with your testosterone, like birth control pills or spiro nolactone or any of the other things that we do to mess with our hormone levels. And when your testosterone drops-We think there are consequences, low libido, increase in UTIs, increase in pain with sex. This is what we're calling perimenopause. And then your regular irregularity of your cycle starts to change. Instead of every 28 days, now it's 35 days, then it's 18 days, then I'm bleeding all the time. And what's happening there is the same thing that was happening in puberty, where your estrogen is going super high and super low, and it's this chaos. And then at some point, the chaos halts to zero, and menopause is a castration event, where your hormones just turn off like a light bulb. And sometimes it's a nice, smooth ramp, and sometimes it is chaos. And you deserve to be treated, cared for, and informed and empowered through every darn cycle that we just talked about, whether you are in puberty just trying to understand how your body works, whether you are normally in your cycle and you're just trying to understand how your body works-
- MRMel Robbins
Or you have terrible PMS.
- RRDr. Rachel Rubin
Or if you have ter- or if this, or if it's not normal, which is, there's no normal. None of my patients are book answers, right? Whether you have PMS or PMDD or PCOS or endometriosis or... We see so much pain and suffering because the people are not following the book, and they are gaslit, and then they are told that it's in their head when they are just not following the rules of the book because the book is old and outdated, and no one taught p- us the updated version.
- MRMel Robbins
And by the book, Dr. Rubin, you're here to teach us that every single one of those issues that you just listed that affect women from the moment puberty starts till the moment we're in the grave, whether it's UTIs or it's pain or it's itchiness or it's dryness or it's painful sex or any of some of the diseases that you talked about, all come down to hormones and are impacted by hormones?
- RRDr. Rachel Rubin
Hormones are a part of this story, yes.
- MRMel Robbins
What is one of
- 14:36 – 16:17
Recurrent UTIs In Women
- MRMel Robbins
the big things that doctors or people think they knew that's actually wrong?
- RRDr. Rachel Rubin
Well, that we treat all UTIs just with antibiotics, that's one thing, and that every-
- MRMel Robbins
You don't?
- RRDr. Rachel Rubin
Well, you do. You treat the infection, but you have to get to the underlying root cause problem, which is the hormonal shifts that are happening with the woman in front of you.
- MRMel Robbins
Wait, you can get UTIs from hormone changes?
- RRDr. Rachel Rubin
Yes, absolutely, and it's so common, and in fact-
- MRMel Robbins
Really?
- RRDr. Rachel Rubin
... that we, we... So, so any kind of hormone fluctuation that happens in your body will affect your genital and urinary health. And so when you f- play with hormones, there are consequences, sometimes good and sometimes bad. So people who, uh, are on birth control pills can sometimes get an increased risk of UTIs, people who are breastfeeding, people who are on hormone therapies in breast cancer, so endocrine therapies, uh, Anastrozole, Tamoxifen, those types of things. Perimenopause and menopause can increase your risk of UTIs drastically, okay? This is a issue called the genitourinary syndrome of menopause, or GSM. Now, it's not just menopause, even though it's called GSM menopause, um, and we- with vaginal hormones. So if you microdose hormones into the vagina, it fixes your bladder microbiome, it fixes your vaginal microbiome, and it prevents UTIs so massively that our research team of medical students, uh, published that we could save Medicare between $6 and $22 billion a year.
- MRMel Robbins
I, I'm, I'm, I don't even know how to interview you because my, my mouth is on the floor right now. I, I, I, I, I just wanna make sure I got that. [laughs] So any kind of hormone fluctuation or hormone change or taking
- 16:17 – 19:20
Genitourinary Syndrome of Menopause (GSM Explained)
- MRMel Robbins
hormones, so whether you're talking about somebody in their teens or 20s on birth control or breastfeeding or somebody taking hormone replacement therapy or on and on and on, can have an impact on getting more frequent UTIs, and one treatment is vaginal hormones, which is wildly effective-
- RRDr. Rachel Rubin
And safe
- MRMel Robbins
... and safe, and doesn't destroy your gut lining the way antibiotics do when you're taking them over and over and over again, is the only thing?
- RRDr. Rachel Rubin
Yes.
- MRMel Robbins
Oh my Go- I've never heard this before.
- RRDr. Rachel Rubin
So it's really important, like, the biggest PSA, a public service announcement, that we need is to get this in the ears of every human on Earth because women are dying. Your, you and your family members are at risk of dying or being in the hospital or missing your children's events because you're going to urgent care for antibiotics for the 10th time. You stop having sex because every time you have sex, you get a urinary tract infection. Most of those problems, not every problem, but majority of those problems are due to hormone fluctuations that are changing the microbiome of the vagina and the bladder. And it can be treated for every aged person, for every person with every medical problem, with a microdosed amount of hormone that is safe for your great-grandmother in the nursing home and you can take for life and can cost you as little as $7 a month, and we can go through all of the options because the most important thing is for your family members to hear this. Um, and we, uh, advocated, for about seven years, we advocated for the American Urologic Association to publish guidelines on this exact topic, and so we published those guidelines in 2025. It's my proudest achievement. Um, and in those guidelines, it talks about the symptoms of, you know, the hormonal shifts that happen not just in menopause, but in breastfeeding, in breast cancer, in birth control pills, in, uh, any type of an- uh, of hormonal type of medications that using vaginal hormones, whether it's vaginal estrogen or vaginal DHEA, prevent urinary tract infections by more than half. But Mel, here's the crazy part. We've known about this since the 1990s. We've had products since the 1970s. And yet, why don't you and your listeners know this? No one ever talkedtaught your doctors this. No one ever talked about it publicly 'cause the two dirtiest words in the English language are vagina and estrogen. And so because we can't say those words, no one is prescribing this. And again, because we decided that all women's health goes to gynecology, right? No other doctor needs to know about women's stuff, 'cause you just go to your gynecologist. And I'll be honest, your gynecologist is busy doing life-saving work for pregnant women, for women with cancer, that this is not their top priority. But then women are dying of urinary tract infections. And so publishing these guidelines are a huge announcement of this is so important. And again, not to confuse everybody, and we can go over this in more detail, but up until this y- this last year, there were warning labels on the vaginal hormone products, okay? And
- 19:20 – 21:16
Vaginal Estrogen Box Warnings
- RRDr. Rachel Rubin
all hormone products, in fact. There were false, incorrect warning labels that said these products cause stroke, blood clots, heart attacks, probable dementia, and you need to use with progesterone. None of those things are true. Not one of those statements is true. And so we've been advocating for changes of those labels for decades. We went to the FDA. We went back to the FDA. We wrote letters. We did all of this. But through grassroots advocacy, through social media, through letter-writing campaigns, through knocking on every door we could find, last year, we got the FDA to announce that they removed the box labeling on vaginal hormone products. And not only that, to be able to stare down the FDA commissioner eye to eye, and I encourage everyone to watch my five-minute testimony, 'cause it's really-- I'm really proud of it. I got to look at the FDA commissioner, and I said, "Your boxed label tried to kill my mother." And I told the whole story of how it tried to kill my mother. And that was in July of 2025. And then in November, we got to stand on stage at Health and Human Services and announce that they were removing the boxed label. That box labeling, your doctor, your family doctor, your gynecologist, your urologist, they would give you this medication, and then the ladies would take it home, and they'd say, "Oh, my God, this is scary. This says it's gonna kill me."
- MRMel Robbins
Yeah.
- RRDr. Rachel Rubin
And so now that those labels are officially off, it's, it's, it's game-changing. And so the PSA becomes, we have to explain to people these medicines were always safe. Not only were they safe, they were life-saving medications. And the label was wrong. It was always wrong. And now we have to teach people how to use it, why to use it, how to write the prescriptions. And so I am sort of working nonstop at every angle, both through the FDA, to patients every day, to teach clinicians every day, because e- each arm of that
- 21:16 – 30:11
GSM, Explained Simply: pH, Thinning Tissue, Burning, “UTI-Like” Symptoms, And Why GSM Gets Misdiagnosed
- RRDr. Rachel Rubin
is so important to save those lives.
- MRMel Robbins
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- RRDr. Rachel Rubin
It's truly old news that needs to get into all the new ears, right? This is not emerging science. This is not new science. This is life-saving medicine that we've known about since the '70s, that we've had in the New England Journal of Medicine in the '90s. And so the question is, why don't I know about this? And it's truly just marketing. It is marketing that nobody has told doctors this, that has told patients this, which is why we fought to get these guidelines created, because you cannot argue with guidelines by the American Urologic Association.
- MRMel Robbins
First of all, thank you for all of that work, and thank you for explaining that, and I wanna be sure that we don't move on until we've completely unpacked this.
- RRDr. Rachel Rubin
I love this conversation, because it's happening already every single day. Because of not just me, but so many of my amazing colleagues on social media, they're yelling, they're screaming, and we are saying the same thing over and over and over again. Basic stuff. GSM, genitourinary syndrome of menopause, is what happens to the vagina, to the vulva, to the bladder, to the urethra, the, the tube that you pee through, when hormones change. So like a plant needing water-The vagina needs hormones. Okay? So if we get really simple, you have babies, right? When you're changing- You have daughters, correct?
- MRMel Robbins
Yes.
- RRDr. Rachel Rubin
You probably remember when you used to change their diaper, it was teensy-tiny. It didn't look like grown-up genitals.
- MRMel Robbins
Yes.
- RRDr. Rachel Rubin
It looks like baby genitals.
- MRMel Robbins
Yes.
- RRDr. Rachel Rubin
Right? That is no hormones. Okay? That's what happens when there's no hormone. It's very thin. It's very fragile.
- MRMel Robbins
Yes.
- RRDr. Rachel Rubin
They pee their diaper all the time.
- MRMel Robbins
Oh, yes.
- RRDr. Rachel Rubin
It is... You put that diaper cream. It's a visual. Anyone who's changed a diaper, they, they know this, right?
- MRMel Robbins
Yes.
- RRDr. Rachel Rubin
And then puberty happens. Your kids stop letting you look down there, but puberty happens, and there is a surge of hormones. You start changing. You get taller. You get breasts. You get meaner to your mother. But your genitals, they change. They transform. They, they respond to estrogen and testosterone. And so there are things that you can see with your eyeballs, like the labia start to grow. The clitoris grows. The area becomes pink. You can put tampons in. You can have sex. You can lubricate. You can orgasm. This is all because of hormones. And so again, when you play with hormones, there are consequences. So anything you do to manipulate hormones can change the health of this tissue. So when perimenopause happens or other things like breastfeeding or birth control pills or-
- MRMel Robbins
So this, this GSM can affect a 20-year-old-
- RRDr. Rachel Rubin
It can absolutely affect-
- MRMel Robbins
... if you're on birth control.
- RRDr. Rachel Rubin
Absolutely.
- MRMel Robbins
Okay.
- RRDr. Rachel Rubin
And so because the tissue responds to both estrogen and testosterone, any changes to estrogen and testosterone can affect this tissue. So without those hormones or with a change of, a significant change to those hormones or a fluctuation of hormones, then the tissue can start changing the way that it looks, but it can also start changing the way that it feels. So you see your pH start to change. So the tissue, which wants to be acidic, the vagina wants to be acidic so it can fight infection. The acid fights infection, keeps you safe, keeps everything, uh, i- as a, as a healthy microbiome. You start to lose that acidity.
- MRMel Robbins
Mm.
- RRDr. Rachel Rubin
The pH starts to rise. Bad bacteria start to grow. The good bacteria start to shrink. You can see, um, a dryness, thinning. Maybe it cracks and bleeds. It starts to hurt. Sex becomes painful. Orgasm gets more difficult. Arousal, you don't feel that same blood flow. You can see the labia minora, those inner wings, can start to disappear actually, 'cause women don't know that their genitals are changing in response to changing hormones. But there's so much hope. Because with microdosing small amounts of vaginal hormones, you can prevent all of this and cure this problem. This isn't like a little bit of lubricant that helps it be more slippery. This is fixing the pH, fixing the microbiome, fighting infections, preventing UTIs, making sex not painful, helping with your natural lubrication. And it is not expensive, often covered by your insurance, and prevents urinary tract infections by more than half, so it doesn't even matter if you're sexually active or not. And by the way, it's not just urinary tract infections. It's frequency, it's urgency, it's leakage.
- MRMel Robbins
Wait. What do hormones have to do with frequency, urgency, and leakage?
- RRDr. Rachel Rubin
Because the whole environment, when it has hormones, it's less twitchy. It's less irritated.
- MRMel Robbins
Oh.
- RRDr. Rachel Rubin
It is the response to the dryness, the thinness, this irritation, where your bladder's just like, "Oh, I don't feel... I'm, I'm not feeling great."
- MRMel Robbins
Yeah.
- 30:11 – 33:19
Why Systemic HRT Often Isn’t Enough
- MRMel Robbins
also how you treat it?
- RRDr. Rachel Rubin
So this is really important, because it can be part of your hormone regimen.
- MRMel Robbins
Okay.
- RRDr. Rachel Rubin
And it should be part. So if you're on a patch or an oral estrogen or pellets or anything like that, if you're doing whole body hormone therapy, you still likely need vaginal hormone therapy. So if you think you do whole-
- MRMel Robbins
Still?
- RRDr. Rachel Rubin
Still.
- MRMel Robbins
Well, I, I literally am like, I'm wearing a patch right now, and I popped my s- my, my progesterone pill last night.
- RRDr. Rachel Rubin
Do you put anything vaginally?
- MRMel Robbins
Like I just [laughs]
- RRDr. Rachel Rubin
Mel Robbins, Mel Robbins, we are about to change your life
- MRMel Robbins
Thank God.
- RRDr. Rachel Rubin
Wait, I can't even believe this
- MRMel Robbins
I feel like I need some-
- RRDr. Rachel Rubin
Oh my gosh, I-
- MRMel Robbins
I need some testosterone too, and I think
- RRDr. Rachel Rubin
So we're gonna have some fun because it, it's really important, 'cause if, again, here's my mission, if I help you, think of how many millions of people we're going to help. Because what you have going on is not rare. And so it, it is so important, and we wrote this in our guidelines, the American Urologic Association, we published guidelines on the genitourinary syndrome of menopause in 2025. My favorite guideline statement is number 11, which says, "People on hormone therapy still should be screened and treated for the genitourinary syndrome of menopause, and we should be giving vaginal hormones." So if you have any symptoms, so I'll ask, do you have any symptoms of urinary frequency, urgency, leakage, UTIs, dryness, pain, anything like that?
- MRMel Robbins
Um, I don't have any leakage 'cause I actually ended up getting bladder surgery.
- RRDr. Rachel Rubin
Yeah.
- MRMel Robbins
It got that bad.
- RRDr. Rachel Rubin
Mm-hmm.
- MRMel Robbins
Um, occasionally dryness.
- RRDr. Rachel Rubin
Yeah.
- MRMel Robbins
Uh, frequency, I go, I go to the bathroom more than I'd like to go.
- RRDr. Rachel Rubin
Women just put up with what's their normal. And so when we add-
- MRMel Robbins
Like, how often should I go the bathroom? I don't even know
- RRDr. Rachel Rubin
... when we, when we add vaginal hormones to your routine, in about two to three months, you're gonna send me an email, I can already see it, I'm manifesting this email, that says, "Holy moly, I did not even know how badly I felt." Right?
- MRMel Robbins
Really? I, I, you know what? I'm gonna admit something, and the team will probably out me on this. I bet I use the bathroom here eight or nine times a day.
- RRDr. Rachel Rubin
Yeah. It's a lot.
- MRMel Robbins
And that's a symptom of GSM, potentially?
- RRDr. Rachel Rubin
Yeah, absolutely.
- 33:19 – 41:00
Vaginal Estrogen Delivery Options: Cream, Tablet, Ring—Benefits, Dosing, Cost, And How To Choose
- RRDr. Rachel Rubin
have some vaginal pH paper, and actually, you can get vaginal pH paper on Amazon.
- MRMel Robbins
Okay.
- RRDr. Rachel Rubin
Um, and the pH of the vagina wants to be four and a half or less. So you take the strip, and you just rub it on the inside of your vagina. You could rub it with a Q-tip and rub it on this paper, and you would look at the color. And if it's yellow or light green, you're in a less than four and a half, which is an acidic pH. If it's dark blue, uh, or a, a higher pH, that is a sign that your vagina is not acidic enough. And so if a patient says she's on vaginal hormones, and we, uh, look at the pH and it's not, and, and it's dark blue, I'm like, "Wait a minute. Are you really using this? Do you have an infection that's explaining why this stuff isn't working? Are you using enough of the thing that we prescribed to you?" So this is something, a vaginal pH strip, you can buy on Amazon. You can have at home.
- MRMel Robbins
Any woman can do this right now and see, like, if you need.
- RRDr. Rachel Rubin
And you can see if, like, this is why you're getting urinary tract infections.
- MRMel Robbins
Wow.
- RRDr. Rachel Rubin
Even if the pH is normal, you can and should still use vaginal hormones. If you're having any symptoms like frequency, urgency, or if you've had any urinary tract infections, uh, we really wanna consider a horm- an underlying hormonal cause. Does that make sense?
- MRMel Robbins
Yes, makes a lot of sense.
- RRDr. Rachel Rubin
So vaginal hormones are micro-dosed amount of hormones, a tiny amount, so it is such a minuscule amount that it doesn't change what your patch is doing, your estrogen patch, or, say, someone who's on no hormone therapy. So a, a 70-year-old woman on no, uh, uh, estrogen therapy, her estrogen levels are zero. Okay? Zero. If she uses any of these vaginal hormone products, her estrogen level still stays around zero.
- MRMel Robbins
Wow.
- RRDr. Rachel Rubin
They may blip up to, like, 20 for a couple hours, the data shows. By the way, your husband's estrogen is 25. So it blips for a couple hours to 20 and then goes right back down to zero. So these are safe. If you have any reason to fear whole body hormone therapy, vaginal hormones are a different bucket. They don't count. They, they, they do not go throughout your body. So the most common prescription, I'm holding up a tube of cream called estradiol cream. This tube of cream, cash price is $13, okay? $13. This tube of cream will last you about two and a half months, so that means for about $7 a month, you can prevent UTIs by more than half.
- MRMel Robbins
And who do I get that from?
- RRDr. Rachel Rubin
So right now you need a prescription, but, um, the head of the FDA said he's interested in looking at making vaginal estrogen over the counter, which would be game-changing because right now you have to get a prescription from your doctor, and there's a chance your doctor doesn't know how to write this prescription. So the guidelines, which we'll link to, are s- tell you how to write the prescription. My website has a free downloadable where you can teach your doctor how to write the prescription. But you take one gram of this cream. So you can put it in an applicator to make one gram, or you can just put it on your finger, on the strip of your finger like you're brushing your teeth when you forgot your toothbrush, and you rub it on the inside walls of your vagina like you put sunscreen on your face. You don't glob it in. You rub it in, so it's not messy or goopy or gloppy, and you just rub it in, and you go on with your day. You do one gram twice a week. A twice-a-week therapy for $13 a tube can save your life.If you don't like creams, and so many women don't like to put creams in their vagina, I get it, I don't like it very much myself, there are other options. This is a generic product. It's m- it's 10 micrograms, like, which is a tiny dose of estradiol or estrogen, and it's a suppository. So you take the applicator, you press a button, and it puts, what, a tiny little pill in the vagina, and you do it twice a week at bedtime, and you set it and forget it, and you're done. It's just so easy to do, and it prevents UTIs by more than half.
- MRMel Robbins
Wow.
- RRDr. Rachel Rubin
Now, if you really wanna set it and forget it, they make a ring. This is called an Estring. It is a localized low-dose estrogen that you put in the vagina, and you leave it in for three months at a time. This is great for your very busy person on the go, or your patient who maybe has dexterity issues-
- MRMel Robbins
Mm
- RRDr. Rachel Rubin
... or dementia, in the nursing home-
- MRMel Robbins
Yeah
- RRDr. Rachel Rubin
... is having issues. So we have lots of patients, they come in, we change their ring every three months, and they go back. I had a patient who had end-stage dementia. Uh, her husband brought her to see me. She was on opioids 'cause she was in so much pain-
- MRMel Robbins
Ugh
- RRDr. Rachel Rubin
... and she couldn't sit. And I examined her, and I said, "I think this is just GSM. I think you just have genitourinary syndrome of menopause." Like, she wasn't able to sort of understand, and we were able to put the ring in, and three months later, I get a call from her husband, and he says, "I would pay any amount of money in the world for that ring, because you saved my wife's life. She has quality of life. She's off-
- MRMel Robbins
Oh, my God
- RRDr. Rachel Rubin
... opioids. She sits without pain. I'm so grateful to you." It's a beautiful story of quality of life matters. And so each product has their own benefits. It's a toolbox, which is so great, because not every woman is gonna want the same product.
- MRMel Robbins
Well, and I would hope that if you're listening and you know somebody that works in a nursing home, or you know somebody who has someone in their family who is struggling with dementia or in a nursing home, the stories that you hear of elderly women living with chronic UTIs is, I, I mean, it- it's a very, very common story, and a ring like this and one appointment could change the quality of their life.
- RRDr. Rachel Rubin
And it's so important. Um, i- it, truly, I can't express it enough of how the nursing homes need to get on board with this, how we need to be helping patients with this, because this is all preventative. So if you do have an infection, yes, you need to be, see a doctor, get a culture. If you're symptomatic, you know, you need treatment with antibiotics. But we have so much antibiotic resistance happening, gut issues that are happening because of all the antibiotics that we're giving people, so anything we can do to prevent this problem, and nothing prevents urinary tract infections to the level that vaginal hormones do. And so getting this, the warning labels coming off because they were never correct is so monumental.
- MRMel Robbins
And it's the same treatment whether you are a 20-something on birth control and having chronic UTIs like I did, or you're a menopausal person, or you're a woman in her 80s or 90s in a nursing home. It's the same treatment.
- RRDr. Rachel Rubin
Totally, same treatment. If you had been on your birth control, I probably would've convinced you to get a hormonal IUD, which doesn't typically cause the problem.
- MRMel Robbins
The Mirena.
- RRDr. Rachel Rubin
Mirena.
- MRMel Robbins
I actually got one.
- 41:00 – 47:38
Dr. Rubin’s Mother’s ICU Story
- RRDr. Rachel Rubin
Yeah. I would love to tell this story-
- MRMel Robbins
Yeah
- RRDr. Rachel Rubin
... actually. Um, so this is really personal. Um, this issue got really personal for me and my family. Um, my mom was a nurse, and my mom was, my mom and I had a challenging relationship, as many mothers and daughters do, and she was an amazing lady, amazing, incredible, talented, creative woman who didn't quite believe in herself the way that, you know-
- MRMel Robbins
Mm
- RRDr. Rachel Rubin
... she didn't quite see herself the way that everybody else saw her. She really was a superhero. And my mom, um, uh, after COVID, she developed a lung condition, a, a pulmonary fibrosis, that was pretty sad and was progressing, and she needed oxygen. And my mom was a lady who lived the crap out of life, and if she didn't have the quality of life she wanted, you know, she wasn't, she wasn't really, uh, happy to, to do more. So she decided, and her doctors decided, to get a lung transplant. And so my mom got a lung transplant and, um, didn't really wake up from the lung transplant. It, it didn't go well. And she was in the ICU for about six months, okay?
- MRMel Robbins
Oh, my God.
- RRDr. Rachel Rubin
She was in Houston at the time. We were, I was in Washington, DC, building my practice, doing all this advocacy work, yelling and screaming and seeing patients, and, and we were navigating this ICU stay. Now, ultimately, she woke up from a coma and got another lung transplant and, and ultimately decided to, um, we couldn't get her out of the ICU. But during the six-month hospital stay, I said to the doctor, she was very sick, and I said, "You know, I'd really like to start her home dose of vaginal hormones."
- MRMel Robbins
Hm.
- RRDr. Rachel Rubin
"Because my mom is immunocompromised. Her immune system is off. She is at risk of getting a urinary tract infection. She's got a catheter in place. She's, I'm a urologist. We're working on these guidelines. I know that she could die of urosepsis very quickly." And I said, "I'd like to start her home dose of vaginal estrogen."And they looked at me like I was insane. And they said, "Little girl, don't you know your mother's very sick?" I said, "Yes, I know my mother's very sick, but I also know the data, and I know that this could save her life." And they said, "Well, don't you know hormones cause blood clots and strokes and heart attacks?" And I said, "That's not true. I know the data. That's absolutely not true." So I showed them the data. I wrote up a whole thing. I sort of clutched my pearls and said, "Do you know who I am?" They didn't really care, to be honest. But they said, "Okay, do whatever you want. We don't care what happens. Sure, you can do the vaginal estrogen, but you have to convince the ICU team." So I go to the ICU team. I said, "Okay, here's the data. Here's what we should do." They said, "Don't you know it causes blood clots?" I said, "No, it doesn't. It doesn't cause blood clots. Here's the data." So they said, "Okay, fine. Do whatever you want. You're a doctor. You can, you know, you can do this, but show us how to write the prescription." So I'm in Houston, and I'm typing out how to write the prescription in their medical record 'cause they have no idea. Well, then the pharmacy calls, and they said, "Well, we can't dispense this to the ICU. There's a big warning alert that said this causes blood clots. The box says it right here. It says it causes stroke, blood clots, heart attacks, probable dementia, and your mother is so sick." And I said, "I know my mother is so sick, and I know the data. I'm on the guidelines committee. I know this better than almost anybody else on, in the world. I want you to give the prescription." So they sent up this tube of estrogen to her hospital room, and the nurses look at it, and they said, "We've never seen that medicine before. We don't know how to give it." They didn't send it with the applicator, and they didn't send it with any instructions. And so I did what any good daughter would do, is I put on gloves, and I did it, and I showed them how to do it. And what was so beautiful was because I couldn't be there every day, but my dad and my brother were, and they advocated every twice a week. 'Cause what happens, for anyone who's been in the ICU, and I see you, and I hear you, and I'm so sorry for what you're going through. What I found out was, right, what we know is that every week, the team changes.
- MRMel Robbins
Yeah.
- RRDr. Rachel Rubin
And we had to do it all over again.
- MRMel Robbins
Oh my God.
- RRDr. Rachel Rubin
And so it gave some, um, something for my dad and my brother to advocate. It gave them something they could control.
- MRMel Robbins
Yeah.
- RRDr. Rachel Rubin
And so it was really actually beautiful because every, like, Monday and Thursday, my dad would call me. He'd say, like, "I talked to the nurse. I made sure it was on the med list. I made sure it's got, you know, they're gonna give it. I'll tell them what to do." And it was something they could control. Now, my mother woke up from her coma, and she came out of it, and she knew that we were doing this, and we were advocating, and she was really proud. And, you know, she thinks I'm a little ridiculous, but anyway, ultimately, my mother decided to go on hospice, and, and my mother passed in November. Now, what's so beautiful about this story, actually, she passed on my 10-year wedding anniversary-
- MRMel Robbins
Mm
- RRDr. Rachel Rubin
... which I thought was a little sad. But what happened on February 12th, 2026, the FDA officially removed the label, and it's my mom's birthday.
- MRMel Robbins
What?
- RRDr. Rachel Rubin
Right?
- MRMel Robbins
Oh my God, you're gonna make me cry.
- RRDr. Rachel Rubin
And-
- MRMel Robbins
They did it on your mom's birthday.
- RRDr. Rachel Rubin
I didn't know it was my mom's birthday. But again-
- MRMel Robbins
Oh
- RRDr. Rachel Rubin
... this is the universe universing, in that on my mom's birthday, the FDA announced that they started to remove the labels that say, "Causes stroke, blood clots, heart attacks, probable dementia." The label doesn't ex- like, the warning label no longer exists. It never should have existed. And so it was so incredible to get to have that story, right? And to-- She didn't get to see me on stage announcing the label removal. She didn't get to experience all of that. But she's up s- somewhere-
- MRMel Robbins
What's her name?
- RRDr. Rachel Rubin
... sort of. Uh, Carol Rubin. Yeah. And so she's somewhere up there, um, you know, helping with all of this stuff.
- MRMel Robbins
What a beautiful-
- RRDr. Rachel Rubin
Isn't it cool?
- MRMel Robbins
... beautiful, beautiful story. Thank you for sharing that. I mean, how incredible. What does that mean to you, especially the part that the label started getting removed on her birthday after she died?
- 47:38 – 49:54
Who Should Consider Vaginal Estrogen Or Vaginal DHEA
- MRMel Robbins
should be on vaginal estrogen, Dr. Rubin?
- RRDr. Rachel Rubin
Yeah, so there's no one who can't have vaginal estrogen. This is really important. There is no one who is contraindicated or shouldn't have these products. There is what we call shared decision-making, in that you have to want it, and your doctors have to want to give it, and you have to come to this conclusion that it's the right thing for you. And in my opinion, it is the right thing for you. Um, and [laughs] if you have any urinary symptoms, frequency, urgency, leakage, any pain with sex, dryness, if you've had a UTI, you should be considered for vaginal hormones. That's if you've had a history of breast cancer, if you've had a history of any types of cancer. Because quality of life is so important, and dying of a UTI doesn't sound very good to me. And so we must weigh, there is ba- there is no data to show harm in these products. In fact, a paper came out, uh, two years ago that said, uh, looked at 50,000 women with active breast cancer, and those who took vaginal estrogen died less. So there are more papers out there that show, uh, less mortality, so dying less, if you use vaginal hormones than if you don't. There are even observational papers that show people who take vaginal estrogen have fewer heart attacks, strokes, things like that. And I think it's because, I mean, again, maybe these women are sexually active. They're more active. They're more interested in their health, so that we see these health outcomes. But you shouldn't suffer. You shouldn't suffer. A- a- and, and so many people, they are constantly feeling itching, burning, dryness, awareness of your genitals. They're grabbing at their pants. They can't wear pants anymore. They can't sit through their Mahjong game. They can't go visit their kids. They can't pick up their grandkids without leaking. And there are therapies and treatments that are inexpensive, that are safe, and that if you use, will work. Now, if you don't use them, if they stay in your bathroom drawer, if you can't afford them, they do not work. But again, this tu- this tube of cream, a, a genericTube of estradiol cream can be as little as $13 a tube, cash price without insurance. So they are now accessible, and so the, if they become over the counter, even better, right? The more we can get this in the hands of the people who need it, the better.
- 49:54 – 55:39
Genitourinary Syndrome Of Lactation (GSL): Why Breastfeeding Can Mimic Menopause
- MRMel Robbins
And if the person who's listening is not in perimenopause or menopause yet, they're younger-
- RRDr. Rachel Rubin
Yeah, so-
- MRMel Robbins
... still a candidate for vaginal-
- RRDr. Rachel Rubin
Absolutely. So if you're breastfeeding, we actually published, uh, I have the greatest research team in the world. You have a good team, Mel. Y- I've heard about your team.
- MRMel Robbins
[laughs]
- RRDr. Rachel Rubin
You have a great team. I have an incri- this, I started a grassroots research group. We published in the biggest OBGYN journal last year on GSL, the genitourinary syndrome of lactation. The fact is, when you are breastfeeding, you're in menopause, and every gynecologist knows this, but they forgot to tell all of us, and they forgot to tell us that actually vaginal hormones were safe. And so GSM and GSL are the same thing, right? Genitourinary syndrome of lactation. So when you have a breastfeeding patient or a lactating pumping patient, right, they will also have frequency, urgency, leakage, more UTIs, pain with sex, dryness, low libido. They have all of those things, and vaginal hormones are safe for them, don't affect your milk supply, and should be used commonly. And in fact, we've done even more research that shows very few of these patients are actually offered a vaginal hormone therapy, and it's being really underused.
- MRMel Robbins
Wow. Wow. You know, one of the reasons why I'm so glad we're talking about this is I think that you live with a lot of things as a woman, and you don't realize it's actually an issue. Like, I just assume that the reason why I go to the bathroom at work, like, seven or eight times in a workday is because I drink a lot of water, or maybe, you know, the bladder surgery that I had and the sling that my bladder is in is couple years, I don't know, five or six years old now. Maybe there's something going on there. I don't, like, I, I just assume, "Okay, well, this is just something I live with."
- RRDr. Rachel Rubin
A- and we see this every day, and again, this is why medicine, the way that it is currently set up, is not meant for women, or really anyone.
- MRMel Robbins
And here's the other thing. Here's the other thing about it, is that it feels like this thing that, what am I gonna do? Make an appointment to go to a urologist?
- RRDr. Rachel Rubin
Right, right.
- MRMel Robbins
What am I gonna do? Go, go to my gynecologist? 'Cause-
- RRDr. Rachel Rubin
Right. Who's got time for that?
- MRMel Robbins
Who's got time for that? And is it even an issue?
- RRDr. Rachel Rubin
Right.
- MRMel Robbins
Or is it just, like, my body? And, and when you said the thing about, like, grabbing at your pants or, you know, feeling a little dry, or things feel a little uncomfortable, like, is this even an issue, or is this just how things are? You know what I mean?
- RRDr. Rachel Rubin
And that's the challenge, because I'll be honest, medicine is not meant for people, um, because if you come to my office and we only have 10 minutes, which is what most doctor's office visits are, and we sit down for 10 minutes, do you think I'm really gonna get to know you, Mel, in 10 minutes? I could be the smartest doctor in the world. Do you think I'm gonna know, or it's gonna be high up on my list to ask you if you're grabbing at your pants because you have some vaginal irritation? That is not gonna be one, two, three, four, or 27 on my list of things to talk to you about in 10 minutes. And so medicine is broken because we are missing the rich, beautiful lives of our patients. And so I have taken myself out of the system, and I'm still trying to figure out how to, how do we do that in a big-
- MRMel Robbins
Mm
- RRDr. Rachel Rubin
... accessible way? But this idea of your support system matters. How you learned about sex matters. Um, how you feel about your own libido, or if you have pain with sex, like, that matters to you and the person you are with. It matters deeply. And so, yes, you don't find yourself going to make an appointment, 'cause you don't even know that there's someone who would listen. And so that's what we're trying to change, this idea of if it matters to you, there is someone who it matters to, like an- another clinician. And, and I always think of it like a pit crew. You have to kind of bring in the people into your pit crew when you have space for it, 'cause you don't always have the space or the energy for all the things at once, right? If you listen to your podcast, you know you can't do all the things in, in one day. You have to kind of meet yourself where you are and give you what you need, but if sexual health or urinary health or quality of life is important to you, there is a growing movement of clinicians who deeply care about these issues, too. We don't have the clinicians to do the work, and that's where I struggle, because there are not enough people who know how to write estrogen prescriptions. It's simple. I can do it. If I can do it, anyone can do it, and that's why we have to teach. We have to get loud. So it's not just enough for me to do this podcast and yell and scream and say, "Hey, this is really important," because women are knocking on doctor's doors every day now and being told no. They're being told, "This isn't real. This is all in your head." Or, because these, these clinicians, they're not bad people. They're, they're doing a lot of things, but they were never taught how to do this. And then there's the fact that we decided not to study women at all, right, in science, and so we're 30 years behind, and we don't have enough funding. We don't have enough research money, so there's a reason your doctor doesn't know anything about this topic.
- MRMel Robbins
And, but you know what we do have? We have you. And so we can go to your website, and we are gonna link to absolutely everything in the show notes. And in fact, you have a printout that you can take to your doctor to explain the guidelines on this-
- RRDr. Rachel Rubin
Yeah
- MRMel Robbins
... and how to prescribe it.
- RRDr. Rachel Rubin
Yeah.
- MRMel Robbins
And so you're making it easier for us, but by being here and sharing all this and teaching us about our bodies and about these life-changing and life-saving options for ourselves, our daughters, our mothers, our grandmothers, our sisters, you're empowering us to be part of the positive change that needs to happen when it comes to women heal- women's health.
- RRDr. Rachel Rubin
I had a woman in my office just this week. She came to see me with debilitating pelvic pain, where her goal to work with me was, "I wanna be able to pick a job where I'm not afraid of being at work because of my urinary pain." And what caused her urinary pain?
- 55:39 – 57:15
Spironolactone And Birth Control
- RRDr. Rachel Rubin
Birth control pills and spironolactone for her acne.
- MRMel Robbins
What? Hold on a second.Birth control pills and that medication for, for hormonal acne?
- RRDr. Rachel Rubin
Yes.
- MRMel Robbins
Which I have two daughters in their 20s.
- RRDr. Rachel Rubin
So those medicines work to block testosterone, and so that's why they help with the acne. Now, I'm not saying you should never be on these medications, but when you play with hormones, there can be consequences. And for this patient, it was causing horrible vulvar pain and urinary pain and urinary tract infections and pain with sex. But she didn't even come to see me, the sex doctor, about her pain with sex. It was, "I can't have a job that I go to. I have to do remote work from home because I am so afraid of being in a place with urinary pain and planning my whole life around it."
- MRMel Robbins
Well, here's the thing that I think is really important, and I, I think it's important because in your 20s as a woman, and your 30s, you just kinda think UTIs are a byproduct of having sex. And what you're saying is if you're somebody that tends to get them more frequently, before you just blame it on sex and you keep trying to get antibiotics and chugging your cranberry juice, that you should go to the doctor, and you should ask for a prescription of vaginal hormones because the research is clear that it is safe, and if you simply use it twice a week, it prevents 50% of the UTIs that you're gonna get.
- RRDr. Rachel Rubin
It should.
- 57:15 – 1:01:21
The Benefits Of Vaginal Estrogen Beyond UTIs And Why Dr. Rubin Calls It “Women’s Viagra”
- RRDr. Rachel Rubin
Now, we need more data on using these products in people, young people, but the reality is, is you won't hurt anybody. You're not gonna hurt anybody using these products. The question is, is the birth control affecting things so much that it will override this, which I don't know. I think it would be okay, but considering other forms of birth control that don't alter testosterone levels, so that's where we love IUDs and things like that because they don't alter your body's formation of these hormones. And so we have to be thinking broader about urinary tract infections from a hormonal lens. You know, it's very frustrating because there are people looking at vaccines for UTIs, these very expensive research projects for UTIs, which I'm all about. UTIs are a massive problem for our healthcare system. But we are not effectively using these vaginal hormone products. My colleague out at Stanford just published a paper a couple weeks ago in JAMA, and it looked at Medicare patients, okay? It looked at, um, over a million patients with Medicare with a diagnosis of a symptom of GSM, so frequency, urgency, leakage, UTI, vaginal pain, any of those. One, you have to have one symptom only-
- MRMel Robbins
Which means you have UTIs based on hormone fluctuation.
- RRDr. Rachel Rubin
Yep, you had a symptom of GSM. Only 9% of patients were given a prescription. 9%.
- MRMel Robbins
So other than being very effective in preventing UTIs, what else does vaginal hormones do for a woman of any age?
- RRDr. Rachel Rubin
Yeah, so besides preventing UTIs, it's essentially Viagra for women.
- MRMel Robbins
Why do you call it that?
- RRDr. Rachel Rubin
Because it helps with sexual health. It helps... So Viagra is actually a wonderful muscle relaxer that helps men get erections. It helps women get erections too, and I'm happy to talk about that. Um, it is a great relaxation drug that increases arousal. Vaginal hormones help with arousal, help with lubrication, help make sex not painful, so it's a fabulous sex drug. Best sex drug ever invented, uh, and so I call it women's Viagra 'cause it truly is. But actually, people don't know this, but Cialis, which is Viagra's cousin, we give to men all the time for urinary symptoms, frequency, urgency, things like that.
- MRMel Robbins
Really?
- RRDr. Rachel Rubin
It's a great drug to take every day, a small dose every day for urinary symptoms, and vaginal hormones help with urinary symptoms. So it is essentially Viagra, but also prevents UTIs. So how is this information not given? It, this, it's so... Here's the crazy thing. When the FDA came out and said, "We're removing these h- warning labels on estrogen products," not one person out there said that these labels should be in place for vaginal hormones. That's how safe and effective these products are, is no one disagrees with me, which is so wild, and yet women d- aren't getting what they need. I have so many women who come to me who said, "I am so tired of thinking about my genitals all the time." It's an awareness. So when we talk about vaginal dryness, we think of it as a cutesy old lady thing of, oh, a little vaginal dryness. It's actually not true. It is a dryness so significant that it affects your quality of life day-to-day.
- MRMel Robbins
And how do you know? 'Cause that sounds like it's cracking and bleeding. Like, what is enough to affect-
- RRDr. Rachel Rubin
You, you-
- MRMel Robbins
Just, like, thinking about-
- RRDr. Rachel Rubin
Your awareness, just thinking about it, adjusting yourself, thinking about the dryness of your skin down there and other places, right? That, that's what... Remember I said, uh, like a plant needing water, right? The tissues, the skin, the inner tissues, the outer tissues need hormones to feel robust. And so that's where the reality is using these products do not hurt you. If you're on hormones already, you can add them to your hormone regimen. If you're not on hormones, this is not whole-body hormone therapy. It is localized, low-dose hormone therapy that is safe for your great-grandmother or, or people with any history. And so, um-
- MRMel Robbins
Or a college student, or a high school student that's having constant UTI issues.
- RRDr. Rachel Rubin
And that's where we really need to get the advocacy and the, uh, research going because this is not just a menopause problem.
- 1:01:21 – 1:05:39
How Hormones Trigger UTIs
- MRMel Robbins
Dr. Rubin, can you just explain a little bit about, like, how the h- how hormones... Like, I'm still trying to understand how hormones impact, like, peeing-
- RRDr. Rachel Rubin
Yeah
- MRMel Robbins
... and, and infections. Does that make sense? Like, I, I, I, I k- I kinda feel kinda dumb that I don't-
- RRDr. Rachel Rubin
No, no, no
- MRMel Robbins
... know a lot about this. But to me, I would never think that hormones have anything to do-With the amount of times I go to the bathroom, whether or not I have trouble going to the bathroom.
- RRDr. Rachel Rubin
Mm-hmm.
- MRMel Robbins
How did, how is that connected?
- RRDr. Rachel Rubin
Yes. So the bladder and the vagina are very close together, and they are filled with estrogen and testosterone receptors. So they are constantly l- s- looking in their environment for hormones to be around, and there are times when hormones are around a lot, and there are times when they fluctuate. And when those receptors are empty, they don't like it, right? So they change. And so without hormones, the tissue changes. The acidity changes. And if you... You know, the vagina and like, and wants to be acidic. And if it is not acidic, the evil bacteria starts to grow. There becomes a dysbiosis, meaning the, the, the right culture envi- the right environment of bacteria changes to what ends up being the wrong environment of bacteria. Okay, so here's where sex becomes important because now you don't have a strong acidic base, and then if you have sex and if your partner ejaculates inside of you, well, uh, remember guys, I'm a urologist, so ejaculate is a big load of basic material. Now, I don't mean basic like every man is basic. We can have that conversation. But it is a big load of pH, high pH, 'cause acid base, big basic material. And so that also then throws off your microbiome even more.
- MRMel Robbins
Can I ask a question?
- RRDr. Rachel Rubin
Of course.
- MRMel Robbins
I'm almost embarrassed to ask you this.
- RRDr. Rachel Rubin
No, no, please.
- MRMel Robbins
Okay. [laughs] Is there testosterone in sperm?
- RRDr. Rachel Rubin
Um, not... That's a great question, actually. I don't think so.
- MRMel Robbins
Okay. So we're just dealing with like-
- RRDr. Rachel Rubin
But that, it's not a hormone. Just that like-
- MRMel Robbins
Okay
- RRDr. Rachel Rubin
... just the fish.
- MRMel Robbins
Okay.
- RRDr. Rachel Rubin
Fish in the sea.
- MRMel Robbins
So it's just the fish-
- RRDr. Rachel Rubin
Yeah
- MRMel Robbins
... but it's the pH aspect.
- RRDr. Rachel Rubin
The pH aspect.
- MRMel Robbins
And because you're-
- RRDr. Rachel Rubin
That's actually not a stupid question. It's a fabulous question.
- MRMel Robbins
And, and because pH is one of the things that hormones help regulate-
- RRDr. Rachel Rubin
Yes
- MRMel Robbins
... and when the pH gets whacked, regardless-
- RRDr. Rachel Rubin
Yes
- 1:05:39 – 1:17:40
The Story Behind The FDA’s Blackbox Warning on HRT
- MRMel Robbins
Well, based on everything you're teaching us, I don't know why every single woman of every single age isn't prescribed or hopefully soon, because of your advocacy, able to buy vaginal hormones over the counter and using it twice a week just for our overall health.
- RRDr. Rachel Rubin
This is why we're so excited about the interest in this. This is why I leave my children and my practice to fly here to come do this, because this is so important. There is nothing to sell. These are generic products. There's no industry around this.
- MRMel Robbins
Oh.
- RRDr. Rachel Rubin
There's no money in this. This isn't like, there's no, i- i- this is truly, like, the public service announcement that is so needed. All I'm doing here is taking a problem that we have always known about with science that we have always had with a product that is safe, and all I'm doing it is packaging it and marketing it and saying, "Every woman on earth needs to know about this." And mind you, up until last year, all these products said that they cause stroke, blood clots, heart attacks-
- MRMel Robbins
Which is not true
- RRDr. Rachel Rubin
... probable dementia, which was 0% true for all hormones, let alone microdosing vaginal hormones. And it is so exciting because the science, this is truly bipartisan and scientifically backed. No one disagrees here. And, and to have an issue that is so impactful that can change so many lives, it's not, like, no one's gonna say I'm wrong. They're just gonna say they're under-educated about it, which is why we're showing up with guidelines. We're showing up with, you know, how to do it-
- MRMel Robbins
And we're linking to-
- RRDr. Rachel Rubin
... with YouTube channels
- MRMel Robbins
... everything-
- RRDr. Rachel Rubin
And that's-
- MRMel Robbins
... in the show notes
- RRDr. Rachel Rubin
... that's why I can't be quiet. [laughs]
- MRMel Robbins
I, I'm glad you're not. Dr. Rubin, can you talk about hormones and HRT?
- RRDr. Rachel Rubin
I love talking about hormone therapy. Um, I-I was so blessed with mentorship. And mentorship, I, this is why I mentor so much, because it truly, this, this cannot die with my, the people above me, and it cannot die with me. We must spread the information and teach as much as we can. Hormone therapy has been around for a very long time, and got a very bad, um, uh, uh, reputation in the early 2000s when a big NIH study came out and said, "Hormones cause breast cancer and cardiovascular disease." And unfortunately, the NIH did a press conference. Uh, I don't know if you've ever seen an NIH press conference. I certainly haven't seen anything else make an NIH press conference. The NIH held a press conference before the study was even published, and they got on stage, and they said, "Hormones are dangerous. They cause breast cancer and cardiovascular disease, and we're halting this study early." Well, then the paper shows up at all the d- this is before social media, so the paper shows up at the doctor's offices.
- MRMel Robbins
What year was this?
- RRDr. Rachel Rubin
This was i- a 2002. I believe the Women's Health Initiative, which is what the study was called.
- MRMel Robbins
Yeah.
- RRDr. Rachel Rubin
It was top of the fold, every newspaper. And Matt Lauer got on TV, every news agency got on TV and said, "Throw your hormones in the garbage. These are going to kill you."
- MRMel Robbins
And it's really important, especially if you're not my age or older, to understand that this one incident in the media and in medicine profoundly negatively impacted women's lives for decades.
- RRDr. Rachel Rubin
Overnight, hormone prescriptions w- went to zero.
- MRMel Robbins
Zero.
- RRDr. Rachel Rubin
Billion-dollar industry went to zero. And we have known forever that hormone therapy prevents fractures, prevents osteoporosis, massively helps with hot flashes and night sweats and sleep, and, and genital and urinary health. That's what hormone therapy is for, is for symptoms for women who suffer, and so many women suffer for very long time. And this, this press conference made all of that go away in one day. And once the papers came to doctors' offices, and the ones who actually read it said, "Wait a minute, that's not what this says. That doesn't make any sense. And my clinic is full of hormone therapy patients, and they all look pretty damn good. I don't understand what they're talking about." Well, what ended up happening was they misinterpreted the data so badly, and they, uh, marketed it so badly, and we could never get back from that. And actually, because of that one press conference, the FDA at the time put a blanket label with a big box around it on all hormone products. Everything that's a hormone product, that says, "These products cause stroke, blood clots, heart attacks, probable dementia." Well, that study was based on just one pill, one dose of hormone therapy. It had nothing to do with the patch that you're on or the progesterone that you take. It had nothing to do with testos- like, it had nothing to do with modern-day hormone therapy. It especially didn't have anything to do with vaginal hormone therapy, which is localized, low dose. And even in that study, women who only took vaginal hormones had less c- no cancer risk, no breast cancer risk. That was published on. So this one study changed the course and trajectory-
- MRMel Robbins
Well, it wasn't even just the study. It was the way the media reported it and the freaking hysteria that it created.
- RRDr. Rachel Rubin
Mass hysteria.
- MRMel Robbins
And for two decades-
- RRDr. Rachel Rubin
Mm-hmm
- MRMel Robbins
... it was just believed that HRT was dangerous, and you shouldn't do it, and it's gonna cause cancer and all this stuff. And so millions and millions and millions of women who would've benefited, whose quality of life would've improved, were either denied it, not offered it, too scared to ask for it. And isn't it true that even some of the researchers came out and said the research was flawed?
- RRDr. Rachel Rubin
Yeah, and that it, it, they came out and said, "Wait a minute, we didn't all agree to this. We didn't all agree to the way this was written and how it was marketed." And the, the tragedy, and this is an American tragedy, actually a world tragedy, the tragedy is not only did women lose access and never get access to these therapies, but we now have generations of doctors who never learned how to write prescriptions or ask the questions. Ask any doctor you know. We get no training, and the data's very clear on this. We get no training in medical school. We get no training in our residencies. That's even gynecology and primary care, where you would expect training. Forget the orthopedic surgeon who's dealing with the fractures or the neurologist who's dealing with headaches or sleep doctors who are dealing with the sleep issues. Hormone therapy is not in their toolbox to offer. And modern-day hormone therapy, that really has much lower risk than the hormone therapy that was studied in that big study. So even that's, those hormones were pretty safe. The hormones we use today are even safer. And so the tragedy is all around because we have so much work to do, not just to teach women why they should go ask for it, but it is likely that they're gonna show up to a clinician who doesn't know how to write the damn prescription. And again, I say this all the time, if I can do this as a urologist, you can do this as an ER doctor, as a primary care doctor, as a gynecologist. And so I, I, I think my, my thesis statement of our work today is there are no grown-ups coming to save the day, okay? There's no grown-ups. We are the grown-ups, and we have to roll up our sleeves and do the work ourselves sometimes.
- MRMel Robbins
Well, I think one of the thing that is incredibly fascinating about what you've, what you've been teaching us is that if, if, if you're, you know, female, you either go to a primary care gynecologist. I don't even think about going to a ur- a urologist, you know, unless I'm having severe bladder problems. And yet what we now know about hormones is that for women in particular, your hormone health is a part of the equation for every single medical issue that you face, whether it's a UTI or frozen shoulder or brain fog or brittle bones or any symptoms that you're feeling, you know, downstairs, all of it.
- RRDr. Rachel Rubin
And that makes perfect logical sense, Mel, because you have hormone receptors in your eyeballs, in your ears, in your hair follicles, in your gut, in your bladder, in your genitals, in your bones and muscles and tendon. Like, there's hormone receptors everywhere. And so, of course, right? But if your doctor never learned how to ask the questions or write the prescription, it will never be a part of your toolbox. And so that's not to say all medical problems are due to hormone issues. Of course not. But how can, how can the rheumatologist deal with inflammation and not talk about estrogen therapy? How can the orthopedic surgeon or the bone health doctor talk about osteoporosis but not estrogen?
- 1:17:40 – 1:19:10
The 4 Buckets Framework For Hormone Care
- RRDr. Rachel Rubin
Okay, so we have four major buckets when we're talking about hormone therapy.
- MRMel Robbins
Okay.
- RRDr. Rachel Rubin
Whole body estrogen.
- MRMel Robbins
What's that?
- RRDr. Rachel Rubin
Estrogen patch, estrogen pill, estrogen pellet, or, uh, uh, estrogen, uh, gels, uh, any type of higher dose estrogen that's there to prevent osteoporosis, help with hot flashes, night sweats. Uh, it ends up helping with your hair, skin, and nails as well, but it's really meant for preventing osteoporosis or treating your hot flashes and night sweats. That's whole body estrogen.
- MRMel Robbins
Okay.
- RRDr. Rachel Rubin
Then there is, if you have a uterus, you, or, or you wanna consider it even if you don't have a uterus, there's whole body progesterone. Now, progesterone protects your uterus from thickening of the... If the estrogen is used, it thickens the uterine lining. The progesterone keeps the lining thin, prevents uterine cancer. So if you have a uterus, you need some kind of progesterone, and it also can help with sleep and mood. So I don't know if you've noticed any sleep benefits with your progesterone, but it can help with sleep, so that's why some people without a uterus like to take it. But estrogen and progesterone is like yin-yang, especially if you have a uterus. So there's whole body estrogen, whole body progesterone, whole body testosterone, which we're gonna talk about right now, and the fourth bucket we've talked about is vaginal hormones, which is separate from all the other three. And so the toolbox is, uh, you can have some of the toolbox. You don't need to have all the toolbox.
- MRMel Robbins
You said there are four types.
- RRDr. Rachel Rubin
Yeah, four buckets.
- MRMel Robbins
You've got full body estrogen, full body progesterone. You've got vaginal estrogen and full body testosterone.
- RRDr. Rachel Rubin
Yep.
- MRMel Robbins
So let's talk about testosterone. Who's it for?
- RRDr. Rachel Rubin
Okay,
- 1:19:10 – 1:23:21
Testosterone In Women’s Health
- RRDr. Rachel Rubin
so testosterone is a human hormone. It is not a gendered hormone. That was very old politics from a very long time ago, and we have to move on. Men make estrogen and testosterone. Women make estrogen and testosterone. Let's quit talking about how one is for boys and one is for girls. It's not true. It was never true. Move on.Okay? Testosterone is a human hormone that we all make regularly, but here's where politics gets in. Okay? So testicles make testosterone, and adrenal glands, these cute little hat-like organs that live above your kidneys, also make testosterone. So for women, their ovaries make testosterone, and their adrenal glands make testosterone. For men, their testicles make testosterone. For women, as they get into their 30s, their t- your testosterone starts to naturally drop. For men, there is also an age-related decline, but it is not as sharp or as, ah, castration-like as estrogen is for women in menopause. Men can... I always say, I use a gas tank analogy. Men get to, like, you know, sometimes half a tank if they're really symptom- and they'll get a quarter of a tank. They never get to zero. Women's estrogens do get to zero. Their testosterone doesn't get to zero, but it does drop in your 30s. Testosterone, my, my thesis statement on testosterone, it's not that serious, people. We want it to be serious. It feels serious. There's all this emotion. There's all this stuff going on about testosterone. It truly is not that scary or serious. We do many scary, serious things as doctors. This is the least scary thing that I do. So for both, for everybody, right? So if a man comes to see me, and he's feeling kinda down, he falls asleep at dinner, his, uh, erections aren't as strong, his libido's getting a little low, and his testosterone is below 300, uh, and he has symptoms, I'm gonna give him testosterone, and he's gonna feel amazing. Okay? Uh, th- testosterone deficiency can happen at any point, so if you have any symptoms of testosterone deficiency-
- MRMel Robbins
Huh
- RRDr. Rachel Rubin
... like I just described, you should get a blood test.
- MRMel Robbins
At any age?
- RRDr. Rachel Rubin
At any age. So symptoms are low libido, low energy, erectile dysfunction, osteopenia, um, uh, uh, you know, so sexual symptoms, energy symptoms, mood symptoms, so we know testosterone helps men's moods. And so again, men's testosterone, there are guidelines. It's, there's about 27 different products. There's different ways to do it, injections, pills, gels, pellets, all these FDA-approved things that happen. For women, we have no FDA-approved testosterone product for women.
- MRMel Robbins
None?
- RRDr. Rachel Rubin
Zero.
- MRMel Robbins
Really?
- RRDr. Rachel Rubin
It's approved in Australia, New Zealand, South Africa, and England.
- MRMel Robbins
Wait, why?
- RRDr. Rachel Rubin
There was a study that happened. A billion dollars went into it. Uh, they studied testosterone, and the FDA came back and said, "Okay, there's five years of data. It shows that it works for libido. It shows that it's safe. There was no major, you know, scary things that happened. Let's go back and talk about it." And the FDA came back and said, "You know, women have breast tissue." It was around the time that Women's Health Initiative study came out.
- MRMel Robbins
So 2002.
- RRDr. Rachel Rubin
So around then. And they said, "Denied. We need five more years of data and another billion-dollar study." I don't know if you know anybody who works in pharma, but they were not gonna do another billion-dollar study, and no one was gonna put another five years, so it died. So it's approved in Australia, it's approved in New Zealand, it's approved in South Africa, and it's approved in England. And if it's safe enough for those people, and we have global consensus, so we actually have a paper called the Global Consensus on Testosterone Therapy in Women. You can read it. Just Google that. Do we agree on anything as a globe? We agree on nothing as a globe, but that paper says, "Global consensus that testosterone therapy is safe for women and works."
- MRMel Robbins
Since we've talked about vaginal estrogen and we've talked about testosterone, I'm now leaning in going, "Well, if I just wanna reduce it down to one thing, if I was gonna do both vaginal estrogen just as something preventative and for my hormone health, and I'm thinking about doing testosterone," which now, Doc, you got me thinking about doing testosterone,
- 1:23:21 – 1:36:36
Vaginal DHEA Vs. Vaginal Estrogen Vs. Systemic Testosterone
- MRMel Robbins
is DHEA an option?
- RRDr. Rachel Rubin
I'm so glad you asked because here's where dose matters.
- MRMel Robbins
Okay.
- RRDr. Rachel Rubin
So vaginal DHEA is, again, microdosing into the vagina to help with the local microbiome, prevent UTIs, pain with sex. It doesn't create a high enough testosterone level to help with your libido the way that we get from whole body testosterone, and we don't think that the whole body testosterone is high enough to get to the vaginal issues, which is why your patch doesn't, isn't strong enough to fix your GSM symptoms. So there is a, a role for instead of vaginal estrogen just using vaginal DHEA. So you don't have to do both. You could just use vaginal DHEA. The one reason why we talk about estrogen so much is it's less expensive.
- MRMel Robbins
Mm.
- RRDr. Rachel Rubin
So often patients can't get the vaginal DHEA. Hey, if you're listening, world, we would love vaginal DHEA to be over the counter. We would love for it to be affordable or covered by insurance because, again, this is life-saving, uh, uh, therapies that should not cost hundreds of dollars for our patients.
- MRMel Robbins
So should you think about the DHEA as, like, vaginal estrogen plus-
- RRDr. Rachel Rubin
Mm-hmm
- MRMel Robbins
... if vaginal estrogen alone isn't doing the job? And one of the reasons why we started with vaginal estrogen is because there has been a lot of advocacy, thanks to you and others, that has made the price drop down, and now hopefully, fingers crossed, it might even become something that's over the counter?
- RRDr. Rachel Rubin
No question, and you understand it so perfectly. A- and it is. It's, like, it's sort of that plus because we don't often use it first line just for accessibility. If it was sort of all options on the table, the vaginal DHEA would be my first choice because it adds the androgen, uh, on, onto it, which the tissue needs both estrogen and testosterone. So we like DHEA. I love DHEA, but I don't have access to it for all my patients, and we're l- we're, we're, we have such a broad audience here that that's why you-
- MRMel Robbins
Mm
- RRDr. Rachel Rubin
... I don't sort of start with that because why, why dangle something in front of you that you can't access?
- MRMel Robbins
Okay, so how do I know my testosterone is low?
- RRDr. Rachel Rubin
So it's, it's, now it's safe for women. It works for women. The science, this is not cardiovascular research, so it's not as precise as we wish it were 'cause no money goes into women's health, and we don't have a product. So the way the guidelines state is that we check a total testosterone, both in men and women actually, not because there is a number specifically that will tell me that you have low testosterone or not low testosterone. But if you come to see me, and we talk, and it comes up that your libido is low, that you're doing great on estrogen and progesterone therapy, but you feel like there, you know, that it's not perfect, you know, and, and libido's the biggest driver that we see with the most data, although patients tell me a lot more improves, then I would check a total testosterone. And as long as the total testosterone was not astronomically high, then you would qualify for a trial of testosterone therapy. And we use generic, very inexpensive male testosterone, and we dose it out for a woman, which is about 1/10 the dose. But-
- MRMel Robbins
And what happens?
- RRDr. Rachel Rubin
After about four to six months, sometimes earlier, but in my opinion it takes about four to six months, that's when women come back to see me and they say, "I feel like myself again, Dr. Rubin." They say, "Oh my gosh, my sex dreams are back. Oh my gosh, arousal is easier. That orgasm was easier. I could actually orgasm without a device. Oh my gosh, Dr. Rubin, I watched TV and my body just felt the tinglies again." They say, uh, you- actually, the data shows and people report their stress incontinence gets a little better. Again, major stress incontinence, there are things to do, but the urethra, the tube that you pee through, is surrounded by testosterone receptors also.
- MRMel Robbins
Really?
- RRDr. Rachel Rubin
So if it, if... Again, think, think muscle, right? If you're building muscle, you're building muscle in your pelvic floor, you're building muscle in your urethra. So the other thing my patients will say is, "Oh, I feel like the gains I'm working," and I see you working hard, Mel, at your exercise.
- MRMel Robbins
I'm trying.
- RRDr. Rachel Rubin
The gains that you make-
- MRMel Robbins
I'm trying, doc
- RRDr. Rachel Rubin
... you, you notice them a little bit more. You get a little more credit, right? 'Cause we see... Now, again, the data is mostly around libido, but libido is a mood, so there's more data that's come out of our friends in England about mood improvement-
- MRMel Robbins
What, what, what are you-
- RRDr. Rachel Rubin
... and mental health improvements
- MRMel Robbins
... seeing in your patients-
- RRDr. Rachel Rubin
So-
- MRMel Robbins
... other than the libido stuff?
- RRDr. Rachel Rubin
Mood. We're seeing people say their mood is better. We're seeing their urinary symptoms are better, their arousals and orgasms are better, their lubrication is better. Uh, we definitely see improvements in libido. Um, and I would say it's, it's, the funniest part of it is the thing I see the most is the, the words, "I feel like me."
- MRMel Robbins
Mm.
- RRDr. Rachel Rubin
And that's the magic words, right? When... So estrogen and progesterone, you feel better.
- 1:36:36 – 1:55:29
Clitoral Adhesions: The Condition Affecting 1 In 4 Women
- RRDr. Rachel Rubin
And, and that's why it went viral. Because it's so simple. And we find that still today, we give women access to their own body, so while I'm examining them, "This is your labia majora. This is your labia minora. This is your clitoris. This is your clitoral hood. This is your vulva, vulvar vestibule. This is your pelvic floor." And we can go through all of those details. In 2017, we p- we looked at thousands of pictures of women's genitals, and we found that 23% of all women who come into the clinic have what's called clitoral adhesions.
- MRMel Robbins
What is that?
- RRDr. Rachel Rubin
Okay, so, uh, I always w-
- MRMel Robbins
23% is one out of every four women.
- RRDr. Rachel Rubin
One out of every four women, okay-
- MRMel Robbins
Has a clitoral adhesion.
- RRDr. Rachel Rubin
Okay, so I always wear sleeves for this purpose. So for everybody l- not here, I have my sleeve over my fist.
- MRMel Robbins
Yeah, okay.
- RRDr. Rachel Rubin
Okay?
- MRMel Robbins
So she's pulled her, the, her sweater over her arm, so her arm-
- RRDr. Rachel Rubin
You cannot see my hand
- MRMel Robbins
... yes, is hiding in there.
- RRDr. Rachel Rubin
Okay. So every clitoris, uh, has a prepuce or a hood or a foreskin, just like a penis that is not circumcised. Now, a penis that is not circumcised, when a man gets an erection, the foreskin goes back behind the head of the penis, and then it looks like a circumcised penis, that mushroom head that goes around a penis. And you can pull back, and, and men with a foreskin, you should pull it all the way back so you can see the whole head of the penis. Well, a clitoris and the penis are the same organ. It's exact same organ. They're made up of all of the same tissues. They look the same under the microscope. Uh, they're the same. So, uh, every clitoris has a hood, okay? And you should be able to pull the hood back to see the whole head of the clitoris, which looks like the head of a penis, has a rim around the edge called the corona, same as with a penis, but 23% of the time, you cannot pull it all the way back. It's stuck.
- MRMel Robbins
Really?
- RRDr. Rachel Rubin
So-
- MRMel Robbins
And that's what a clitoral-
- RRDr. Rachel Rubin
Clitoral adhesion
- MRMel Robbins
... adhesion is? It means the hood of it is-
- RRDr. Rachel Rubin
It's stuck
- MRMel Robbins
And how, how could that-
- RRDr. Rachel Rubin
And it could be... And okay, so here's... So in 2017, we were the first to published what... We were the first, uh, to publish that it is either mild, where you can see most of the head of the clitoris, moderate, where you can see a little less, or very severe, where you can't see it at all and you can't pull it back, okay, 23% of the time.
- MRMel Robbins
23% of the time?
- RRDr. Rachel Rubin
Yeah. This was published in 2017, and that was all of the world's literature on this problem.
- MRMel Robbins
If you have clitoral adhesion-
- RRDr. Rachel Rubin
Yeah. Doesn't mean anything
- MRMel Robbins
... does it impact your ability to orgasm? Like, what, what, what, like-
- RRDr. Rachel Rubin
So here... So, so up in 2017 we had no idea. This was just an observation of, okay, 23% of people have this. So what does it mean? Is it normal? No doctor is taught how to examine the clitoris or ever routinely examines the clitoris. Can you imagine, I'm a urologist, if I was told, "Don't examine the penis. Don't touch a man's penis. You might make him uncomfortable." What if you have a clitoral problem? What kind of doctor do you go see? There is no doctor trained in the clitoris. There is a part of your body-
- MRMel Robbins
Wait, as a urologist, they don't train you in this?
- RRDr. Rachel Rubin
No. No one. In fact, when you are a medical student learning to do a, a, a pelvic exam, no one teaches you to go near the clitoris. So a penis, lots of things can go wrong with it, right? So much can go wrong with a penis. Couldn't all the same things go wrong with a clitoris? Of course they can, but nobody's looking. So 2017-
- MRMel Robbins
Thank God you are, Dr. Rubin
- 1:55:29 – 1:58:30
The 2 Most Common Causes of Painful Sex
- MRMel Robbins
Dr. Rubin, that sex shouldn't hurt. What are the most common causes of pain with penetration that you're seeing?
- RRDr. Rachel Rubin
So there's really the two major problems. There's a third one that's a little bit smaller, but the two giant problems are, number one, hormonal changes. So anything that can affect your hormones, birth control, r- uh, acne medications, breastfeeding, endocrine therapy for breast cancer, um, uh, perimenopause and menopause. That is so common to have pain with sex and so treatable with vaginal hormones, which we talked about at length. So treatable, like amazingly treatable. The second most common problem is often comes with the first problem, is when your muscles are really, really tight. And so if you have tight, tight, tight, tight muscles, think squeeze your eyes closed as much as you can, it's hard to sort of stretch that tissue and get it to open. So what often happens, the hormones cause the... like a sunburn-like pain.
- MRMel Robbins
Mm.
- RRDr. Rachel Rubin
Your body guards and tightens to protect you. You fix the sunburn, the body is still tight, and that's where our rehab, our physical therapy friends come in, and dilation, dilators, vibrators, things that rehab the tissue because you have to fix the sunburn, fix the tissue, and then the muscles have to be healed. But the muscles can have problems on their own. You could have hip problems, you could have back problems, you could have endometriosis causing muscle problems, or you could have all these things that cause pelvic floor tightness. Not as common are problems with nerves. So you can have too many nerve endings in that part of your body.
- MRMel Robbins
Mm.
- RRDr. Rachel Rubin
And there is surgeries that sometimes we have to do for this problem. The most important message I can tell your amazing listeners isSex should not be painful, and you deserve a diagnosis. Just like you don't show up with face pain, you wanna know, is it, like, where is the problem?
- MRMel Robbins
Is it the teeth?
- RRDr. Rachel Rubin
Is it-
- MRMel Robbins
Is it the eyes?
- RRDr. Rachel Rubin
... the teeth? Is it the nose?
- MRMel Robbins
Is it the eyes?
- RRDr. Rachel Rubin
And, and, and just like there is a specialist all over your face, there are specialists, and much fewer, for this part of the genitals because we haven't valued or cared about this part of the body for women, so it is likely that your general doctor who you've been seeing for a long time isn't necessarily, they might be, but isn't necessarily trained in the specific diagnosis. So we do have many patients travel to see different, some of us who are specialized. There is, there's, there's, you know, um, 1,700 within our women's sexual health specialty. Not everyone is a, a doctor, but, uh, there, there's, there's, um, not enough of us. There's not enough specialists, but sometimes you have to go find someone who's gonna give you a diagnosis, because that matters then for treatment.
- MRMel Robbins
Mm.
- RRDr. Rachel Rubin
And that's where the mirror comes in handy, because when you can see what's going on, again, it, you never heard of a vulvar vestibule, and it took me-
- MRMel Robbins
Never. Never in my life
- RRDr. Rachel Rubin
... but it took me two seconds to explain it, and it made so much sense to you that hormonal treatments would be helpful for that, right? It took two seconds. So to be able to give women information about their diagnosis, I didn't realize how much medicine that was. Like, even before they get the treatment, just the validation that what they have is real and it, it's diagnosable, and they're, they can see it with their eyeballs, life-changing.
- MRMel Robbins
Life-changing. I would love
- 1:58:30 – 2:08:42
How To Advocate For Yourself At The Doctors
- MRMel Robbins
to focus on a couple recommendations of exactly what to do once you start to understand everything that you're talking about. If someone only has a 10-minute appointment with their, you know, gynecologist or their primary care doctor, what exactly should they say to be taken seriously?
- RRDr. Rachel Rubin
[sighs] I think it's really important for patients to educate themselves in, in as much detail as they possibly can and find doctors who they can work with as part of their pit crew. And I actually think it, it's important for patients to go to doctors and say, "Hey, I know you didn't learn everything in med school, and I know you don't know everything, and I, I am really interested in this topic. Do you know someone or are you the right person to help me with these problems?"
- MRMel Robbins
Ooh, I love the way you just framed that.
- RRDr. Rachel Rubin
And, or these-
- MRMel Robbins
Are you the right person to help me with this?
- RRDr. Rachel Rubin
Are you the right person to help me with these issues? Because so many of your clinicians, I, I know a lot about the things I know a lot about. They're, if you asked me about diabetes right now, I would look crazy, and I don't know anything about diabetes. I don't know anything about thyroid hormones. I don't, I mean, I know a little bit, but, like, but I am not an expert in the things I'm not an expert in. Your doctor doesn't know everything, and the key is to find someone who is curious, who is kind, who is thoughtful, who is willing to be a member of your pit crew, but I've never fixed a patient on my own. I wanna be very clear about that. I have never fixed a patient by myself. The patients who do the best are the ones who have a team, and they are the center of the team. They are the boss, the CEO, they're the race car driver, and they take a, they take responsibility of the team. You have to understand what you get in 10 minutes, and you have to come prepared, but also show some kindness and, uh, to your clinician, 'cause they don't wanna spend 10 minutes with you either. They also would like to spend more time with you-
- MRMel Robbins
Mm
- RRDr. Rachel Rubin
... but your insurance company doesn't give a crap. They only want you to have 10 minutes, and so I think the bad guy is not always the doctor who is under-educated in some of these issues. It's the system as a whole.
- MRMel Robbins
If you're a healthcare provider, a nurse, a doc, somebody who is in the medical profession, and this is all new information to you, because I also think this is one of those episodes that people are gonna send to their sister or brother who's a nurse. They're gonna send to their partner who may be a doctor. They're gonna send to their friend who's the gynecologist of the friend group and say, "Oh, my gosh," like, "You gotta hear this." Where, what is the best place for a medical professional or somebody working in healthcare to go to become more educated about what you've just shared?
- RRDr. Rachel Rubin
You can learn new things.
- MRMel Robbins
Yeah.
- RRDr. Rachel Rubin
Your clinician can learn new things, whether it's taking my course online while you drive to work. Uh, the Menopause Society has great content. ISSWSH, the International Society for the Study of Women's Sexual Health, isswsh.org, has a great find a provider and hormone course. Um, there are more ways to learn how to do this, more than ever before. My friend Heather Hirsch has awesome content. Kelly Casperson has an amazing podcast and is a dear friend of mine. Uh, ISSWSH has amazing content. They have patient-facing materials called Prosalia website. We've had thousands of people take our course and actually say, "Oh, wait a minute, I can do this as a dermatologist, as a plastic surgeon, as a rheumatologist, as a neurologist." I-
- MRMel Robbins
Orthopedic surgeon.
- RRDr. Rachel Rubin
Orthopedic surgeon. You can learn how to do this, and you can do it quite easily. And so if I give you the building blocks and the confidence to say, "Hey, if I can do this as a urologist, you certainly can do this, and here, I will help mentor you," um, that's really what it's gonna take. But, um, I'm hopeful for, there's more money in this than ever before. There's more industries in this than ever before.
- MRMel Robbins
Dr. Rubin, if you could speak directly to the person that's listening, if they take one action from everything that you've shared with us, what would that one thing that's the most important thing to do be?
- RRDr. Rachel Rubin
So education is the most important thing, and by listening to this, you can check that box off. You're incredible. By investing in your body, your education, and your knowledge, you cannot go wrong. You have to learn yourself to figure out, who do I need to go see to get my customized answer? Because you deserve it, right?
- MRMel Robbins
So Dr. Rubin, for somebody who's been hanging on every word, and now you've opened the door, we wanna walk through and just jump in and learn even more-Where do we go?
- RRDr. Rachel Rubin
We're all lifelong learners. I'm learning new things every single day. And so a great place is to follow me on social media, 'cause you can learn the new things that I'm learning while it's happening. That's Dr. Rachel Rubin on social media. Our website is a wonderful place for education, so rachelrubinmd.com. You can find our courses, our, uh, our updates. Our newsletter's very popular. Um, we tell you about all the new research that's going on, which is really excellent. And then this has been an insane year. Not only were we able to announce the FDA box label changes, but I have been a part of three incredible documentaries that are all able to be watched now. Right now, get on your TVs and start watching. The first one I couldn't be more proud of, Paramount Plus, and it's called Pink Pill. You must watch this documentary. Your jaw will go on the floor. And this documentary got made. It is all about the drug that is FDA-approved for low libido and how hard it was to get advocacy through, through the FDA. It is a must-watch movie. It only got made because I did a free Zoom call for a friend of mine, and there was a producer in the audience and, and the movie got made because of that. I'm in it. I'm not the main star of it, and it is fabulous. The second thing that's a must-watch is the Balance documentary series. Again-
- MRMel Robbins
The Balance?
- RRDr. Rachel Rubin
Balance. It's called Balance. It is all about perimenopause. It is these l- lady monks who, uh, are also a documentary filmmaker that were going through perimenopause. It's so fascinating. They were like, "Wait a minute, I am, like, doing yoga and mindfulness, and my soul is great. Why am I having hot flashes, night sweats, and I can't sleep?" And they go on this spiritual journey to learn everything they can about perimenopause and hormones. So they interview all of the experts. They go on their own journey. It's a four-part series on Apple TV. Uh, it is absolutely fabulous. I'm in it. I'm not the star, but I have some really funny lines in it that I think will make you laugh. Uh, obviously, I, uh, I... Women urologists have to be funny, by the way. It's kind of a rule. Um, and then the third one is The M Factor, uh, uh, Before the Pause. So The M Factor was a great PBS documentary about menopause, and they just made the prequel about premenopause. And so again, so they interviewed so many experts all about perimenopause. I'm in it. I'm not the star. Uh, this is, like, the best. I always say I have sidekick energy. Like, I love being in things but not, like, the main event, which is why this makes me very uncomfortable, Mel. Um, but these three documentaries are just showing how much excitement there is about this topic, how much the people wanna know about it. So check out our podcast. Check out the books that are out there. Follow us on social media. We are building an army of education and advocacy, and we would love to have you join us.
- MRMel Robbins
I absolutely love that, and what I, what I really appreciate is that you've empowered us to be honest with ourselves about the things that we're living with that we may not have to live with. Like, there are things that I learned today that I wouldn't even have thought to make a list and go talk to somebody or learn more. And so I just, I am on the floor about everything that you have shared with us today. This has been absolutely extraordinary. Dr. Rubin, what are your parting words?
- RRDr. Rachel Rubin
You matter. Your life matters so deeply, and you deserve a team around you to help you with that and get you to whatever your goals are. And I just wish you all of the success and the optimized life ever, 'cause you deserve all of that.
- MRMel Robbins
Well, Dr. Rachel Rubin, you are a gift to all of us. On behalf of every single woman that will listen to this, I just wanna thank you for the work you're doing, for the research that you're doing, for the advocacy that you've been doing. You are saving women's lives. You're changing medical care for women, and I think this is just the beginning. And it's a real honor to spend this time with you, and I am absolutely grateful for you, for the work, for everything that you taught us today. Thank you.
- RRDr. Rachel Rubin
Thank you so much for having me.
- MRMel Robbins
Of course. It won't be the last time, I'm sure. And I also wanna thank you. Thank you for caring enough about yourself and the other women in your life, for listening to this, for sharing this. I have so much that I'm now thinking about. I have so many people that I'm sharing this with. I'm sure you feel the same. I cannot wait to hear your feedback about this, and I'm really honored that you and I are now gonna be a part of a wave of positive change that spreads around the world one woman at a time based on what we've learned and how empowered we now feel to take better care of ourselves and to advocate for the things that we deserve and need in our lives. And in case no one else tells you today, I wanted to be sure to tell you, as your friend, that I love you and I believe in you, and I believe in your ability to create a better life. And as Dr. Rubin just said, you get one life, and I really want you to be proactive about advocating for yourself and doing what you need to do to feel good in your life and in your body, and everything you learned today is gonna help you do that. All righty, I'll see you in the very next episode. I'll welcome you in the moment you hit play. And thank you for watching all the way to the end, and you're gonna love this next video, and I'll be waiting to welcome you in the moment you hit play. [outro music]
Episode duration: 2:08:43
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