The Hotflash inc podcast
Hotflash inc is an evidence, expert and human-experience driven podcast looking for the true truth in perimenopause, menopause and beyond.
In more than 100 episodes menopause and midlife journalist and host Ann Marie McQueen has spoken to a wide range of experts from around the globe, including practitioners, activists, researchers, doctors and industry leaders about this perplexing transition we still know too little about. She’s talked about her own frustrations and personal experiences. And she has connected with a perimenoposse of powerful women in the midst of a perplexing transition.
Hotflash inc is among the top 1.5 percent of podcasts in the world according to Listen Notes. It was named the number one podcast in women’s health in August 2023 by GOODPODS.
The Hotflash inc podcast
59. Dr Rachel Rubin: "Too often the word hormone scares people"
Dr. Rachel S. Rubin is one of the most important voices on social media, advocating for women’s sexual health. Her frank manner and deep educational background – she is that rare combination of board-certified urologist and sexual medicine specialist and one of only a handful of physicians with fellowship training in sexual medicine for all genders – makes her uniquely positioned to talk about the range of issues we can face during the perimenopause transition.
She’s also education chair for the International Society for the Study of Women’s Sexual Health and associate editor for the journal Sexual Medicine Reviews. Dr. Rubin completed her medical education at Tufts University, her urology training at Georgetown University, and her sexual medicine fellowship training with Dr. Irwin Goldstein in San Diego. We spoke at the Menopause Shift Summit.
Highlights:
- How the push for ‘natural’ hurts our sexual and urinary health
- Why urinary tract issues are directly linked to menopause
- The conversation around women’s sexual health needs to focus on biology too, not just psychosocial factors
- Why your sexual health takes a village
- Hormone therapy is THE solution for genitourinary syndrome of menopause
- Breaking down the different kinds of vaginal hormone therapy: estrogen, DHEA and testosterone
- All about testosterone: pellets, systemic and vaginal
- Orgasm problems and what we can do about them
- Focusing on joy and pleasure, not penetration
- Hollywood’s sex problem
- Kegels and apps and lasers
Where to find Rachel:
Web: RachelRubinMD.com
Instagram: @drrachelrubin
Twitter: @drrachelrubin
Midlife is freaking hard. Let's flip the script.
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when it comes to women's sexual health, society has ingrained in us that it's. All psychosocial, it's all emotions, it's all talking, and yes, that's a part of it. It's a big part of it, but we don't talk enough about the biology
Ann Marie:I wanna dive right into it, but I'm gonna be very. General at first because everyone always says, go see a pelvic health specialist for the problems that you're having during menopause. Do they mean go see a, a urologist? Any urologist, you,
rachel:so it's a great question, and um, it, it's kind of confusing, right?
Because menopause, I believe, has the worst PR campaign in the history of the universe. You know, everyone says, oh, it's just hot flashes and night sweats, and those go away. So suck it up, pick yourself up by your bootstraps, breathe deeply and meditate and you'll be fine. And that is, Just a absolute horrendous, thing that we tell women. And so really, menopause is a, a stage of life where your body is no longer producing hormones. Yes, it is natural, quote unquote, but it can affect every part of your body, your brain health, your bone health, your bladder health, your musculoskeletal system, your your heart. And so. There is no one doctor in charge of all of those things and responsible for all of those things. Think of a doctor for men that is responsible for absolutely everything. It doesn't exist, nor does a menopause. That's only doctor for all. Women over 50 exist. And so you have to see someone who is menopause aware. And so, in, in America we have, a wonderful society called the North American. Society, which certifies people who have interest in menopause, but that doesn't mean that they're experts in every single aspect of menopause. As a urologist, I am, and, and I'm a sexual medicine specialist. I did a fellowship training. So my expertise is in sort of, preventing urinary tract infections, making libido good, and orgasm good, and arousal. Persistent and, and those are the things that I focus on. I'm probably not the best person for bone health or for, you know, but I do help bone health by, you know, giving evidence-based hormone therapy, which will prevent, bone problems in the future. So I think it's a misnomer to think that one doctor can do it all.
Ann Marie:It would be impossible to have a menopause specialty. I can't imagine how you would do that. You wouldn't be able to, you'd have to be a doctor of everything.
rachel:Well, I think they're, you know, primary care doctors and there are primary care doctors who specialize in menopause and they're aware of everything, but they often will have to refer to specialists where, you know, they who are also menopause aware.
You know, because it is really hard to be. Heard and absolutely everything. I know it's shocking, but, it is a difficult thing to find.
Ann Marie:What do you think people are getting so wrong in this space? You're active on social media. What do you see that just makes you a,
rachel:you know, I think there is, people are well-intentioned generally, but I think there is always a push to, I have something to sell you.
And also this idea of natural that everything can be done naturally is actually kind of problematic because you can do yoga. Forever and ever and meditate forever and ever. But it is not going to make your hot flashes go away and it may not get your sleep to improve. But safe, effective evidence-based even F D A approved, natural estrogen. Yeah, I said natural there, you know, but, but there are f D A approved products, you know, that are safe and effective and we have lots of evidence that will. Actually help, really help. and I think this fear of medications and fear of f d A approved products is, is a big problem that's happening in this space. So, whereas, you know, good nutrition is important and good sleep is important and all of those things are really important. Sometimes medical therapy is just as important and can be done just as elegantly.
Ann Marie:Okay. And so what do you, what sort of problems, we talk, we hear about the genitourinary syndrome syndrome of menopause. This encapsulates a whole bunch of things. When people come to you, what is the range of things that you see? So women may not even know or connect that to their perimenopause transition or the,
rachel:yeah. Thank you for asking that question and, and I'll give you an example. I have say, I have a woman who comes in to see me.
She's 52, sorry. Let's say she's 68, and she comes and she says, oh, Dr. Ruben. I went through menopause years ago, and it was super easy. I didn't really have bothersome hot flashes or night sweats. I said, okay, why are you coming to see me? She says, well, Dr. Ruben, I'm getting urinary tract infections. I get up all night long to pee. Uh, I can't even go out with my friends cuz I have horrible urgency. Um, o of urination. I'm leaking all over the place and my goodness, I have osteoporosis, low libido, pain with sex. Um, you know, and, uh, gosh, I'm miserable. And I look at her and I say, all of that is menopause. All of that is menopause. And just because you're 68 doesn't mean you're not still being affected by the lack of hormones in your body. It affects so many parts of your body. And so I think that's really the key. You know, that, that, that it, that you have to think broadly about menopause. Okay. So let's sort of unpack. Libido. A lot of people hate the word libido, but everyone talks about desire, lack of desire. This is part of your job too. Yeah. So a, again, not all urologists are experts in libido and orgasm and arousal, or even sexual pain, but my fellowship training was in sexual medicine, and so I take care of sexual problems for all genders. And so, You, there are many, several specialists of us out. There're not a ton who focus on the female, libido and things like that, but it's a really interesting topic. Libido. you know, let's think for a second when teenagers can't get their hands off of each other, right? No one says, oh, they have deep, meaningful conversations. Oh, they have a deep, meaningful connection with each other, and they're really understanding each other on a deep level. Nobody says that about teenage, corny teenagers. It's very hormonal. And everyone gets that. And so this idea that a lack of libido and a lack of wanting to. You know, you can't keep your hands off of each other, is also probably very hormonal. And so, it's what we like to call bio psychosocial. And I treat, men about probably about 50% of my practice is men, is, male patients. And. When we, when it comes to men's sexual health, it's all biology. We talk about erections and blood flow and penises and, and muscles and testosterone and not enough psychosocial. Right. We should probably talk more psychosocial, but when it comes to women's sexual health, society has ingrained in us that it's. All psychosocial, it's all emotions, it's all talking, and yes, that's a part of it. It's a big part of it, but we don't talk enough about the biology of what is this? Is your body maybe off all estrogen and testosterone? You know? Or this is your body without dopamine in the its brain. And so there's so much rich biology and we see it when we treat patients. Right. I had a patient come in just the other day who said, oh my God, Dr. Ruben, I thought I was never gonna have sex again. And now I want it. I like it. I think about it. My partner can't keep up and now they're coming to see me, you know, because of their issues. And so I think this idea that there's no biology is not true.
Ann Marie:So it's a combination bet of, of, of biology and psychology. And how do you get to that? Because you're not a psych. You're not a marriage counselor.
rachel:I have so many friends. Uh, and really, it, it takes a team. This is why it is not one doctor who fixes everything and it takes time. I know you're not, uh, in America, but, you know, doctor visits here about 10 to 15 minutes.
And the idea that you can unpack someone's whole biopsy, psychosocial history in 10 to 15 minutes is a joke. And so I don't play those games and I take an over an hour with patients when I meet them and I ask them every question in the world that you could ever imagine about, you know, their sexual function, their sexual health, their medical problems, their surgeries, their, how, the things are in their relationship, all sorts of things. And then we come up with a plan, and it's what I like to call a bio psychosocial plan that includes different team members. So it may be myself and, you know, Lisa. Street, who's an amazing sex therapist. It may be Jen down the street who's an incredible physiotherapist, you know, or pH or pelvic floor physical therapist as we call them here. And, and so maybe it's a pain doctor or a cancer doctor that I have to work with. But really it takes a team to really figure out what we can do. And sometimes it means seeing the partner cuz sometimes it's the partner's issue. And really getting the partner into the conversation which makes it fun to be a sexual medicine doctor cuz every love triangle that comes into my office I can help with because my e. In sexual medicine and not one particular gender.
Ann Marie:When you said love triangle, do you mean like the person, the person and the problem or what?
rachel:maybe. Or maybe there's, maybe there's a, a, a throuple, right? There's all sorts of things that we see, we see, we see all sorts of things in our area.
Ann Marie:That is true.
You always see vaginal dryness I think it's the fear for women, right? Why do you think the focus is on vaginal dryness and how much of the problem is.
rachel:So vaginal dryness is very common, in menopause. And the reason is the vulva, the vagina, the bladder, the urethra are very, very rich in hormone receptors. They have tons of receptors for estrogen and testosterone actually.
And when you, don't. Make estrogen and testosterone anymore, the tissue is screaming for it. It wants it, it dries up, it's irritated, it's raw. It actually loses its acidity to fight infection. And so it is, the symptoms that you see with this lack of hormones to this tissue are vaginal dryness, pain with sex, but you also see a lot of urinary tract symptoms. Frequency, urinary urgency, leakage, and something that can actually kill you is urinary tract infections. And so without hormones in this tissue, you can potentially over decades of this problem happening, eighties, nineties, you know, die of a urinary tract infection, which we could have prevented. With some local hormones to the tissue, which are very safe and effective. And I think the problem is we think about it as a sex problem, but it's not just a sex problem. I had a patient just, the other day who said, geez, it hurts to walk, it hurts to wear pants, it hurts to wipe myself, and I'm getting up all night long to urinate and I can make that go away with a very, very, Easy, safe, and effective, a vaginal hormone product. Now, the issue is yes, lubricants and moisturizers and some of these natural products that people talk about work to kind of help with some of the symptoms, but they're like band-aids. They do not fix the problem, and it's very safe and easy to fix the problem. And then use the band-aids if you want those as well. But I think too often the word hormone scares people, but it shouldn't because not all hormones are the same, and not all the data for every type of hormone is the.
Ann Marie:So if someone came into you with those kinds of problems and you said, I can fix this with vaginal estrogen, would that be the route you would
rachel:either, so, so I say vaginal hormone because it's not always ge.
Remember I said there's testosterone receptors as well, and so, you can use vaginal estrogen. It's safe, it's effective, it works for. Fabulously and, and it's wonderful. And just like, wearing your seatbelt or brushing your teeth or putting moisturizer on on your face, you have to do it forever. You never get to say, oh, I wore my seatbelt for 30 years. I don't have to do it anymore. And so vaginal hormones are for life. if, and, and that's, I think, a big misnomer out in the community. And so, There is also a D H E A, which is a precursor to estrogen and testosterone, which is approved in our country that works fabulously as well. So I don't say just estrogen, you just kind of say vaginal hormones, because there is evidence that D H E A and some testosterone products, but what we have f d A approved in our country is vaginal estrogen, D H E A. There's a Premarin cream, which is approved here, and then an oral option called oen. It's a pill that you can take that can help this problem as well.
Ann Marie:So the D H E A, why would you go that route? It's a great question. In America, it we are, we are often forced to use what the insurance company tells us that we can, or what the cheapest cash price option is, which is often a vaginal, estrogen product, which is okay.
It works. And, and I typically like to use a small estradiol tablet, that goes in the vagina every day for two weeks and then twice a week till death do they part, like forever and ever and ever. D H e A is a fabulous product and I wish it was more affordable and available in America because it's a nice product, because it adds that androgen component, which there's a little bit of data. If patients don't respond to estrogen, if you switch them out to the D H E A product, they actually respond to that a little bit better. So it can be a nice, therapy as well. And it's also what the patients like to use. And so one's daily, the, the D H E is a daily product versus a twice a week estrogen product. So I like having tools and options for my patients, but sometimes they're not always all the same affordability for patients.
Ann Marie:And what about testosterone? I heard, someone presented at NAM at nams, the North American manifest. Annual meeting two years ago, a nurse practitioner and she was talking about using testosterone and applying testosterone directly, directly to the clitoris in the area for, she said even sometimes there's something called muted orgasms, cuz I wanna talk about problems with orgasms after this, but it seems that the use of testosterone.
Is also controversial cuz they talk about it can sort of affect the area. So can you just kind of cut through that?
rachel:So testosterone is a deliciously controversial and complicated topic. I love testosterone. I use testosterone in all my, in, not all my male patients. All my male patients who need it, right when they have low testosterone.
We have lots of options in America for testosterone, for men, for libido, for, it helps with erectile function, it helps with, mood and energy. It helps a little bit. It's not, you know, the holy grail of hormones, but if you need it, it helps a little bit. Same story with women in testosterone. So if you look in Australia, for example, they do have a, a whole body testosterone available by their, their governing bodies. And it works great in the patients who need it. So what does it help with? It helps with libido. That's where we have. Data. But probably it ultimately will will prove to help with mood and energy and muscle and pelvic floor and, arousal disorders as well. We certainly know, it helps with vestibulodynia, which is superficial pain with sex. So if you have pain with penetration, we know adding testosterone to that tissue can be extremely helpful as well. But the problem that we have in America is there is zero F D A approved testosterone for women. And it's not because it doesn't work. It's all money and politics. It is all money and politics. And so it's a big frustration that we have because we have to use either f, fda, A approved products for men, but put them in sort of one 10th the dose for our female patients. Or we have to use compounded products, which I prefer using myself, I prefer using F D A approved products because I know what's in it. I know it's been regulated. I know that somebody's been looking under, you know, under the canister and making sure you know what's in it, is what they say is in it, you know, so, so that's the way that I do testosterone therapy.
Ann Marie:And do you prescribe it to apply directly like a cream
rachel:it totally depends. It depends on the pa. There are many different ways to give testosterone, and so it depends on the patient and the problem that they're coming to see me for. So for the most part, the most data that we have out there is on low libido or hypoactive sexual desire disorder. And that tends to be using a topical, a testosterone on your calf every day.
And over time, we can build up. Systemic levels. And so we don't have much data about applying it directly to the clitoris. But if you do, like if you think of a transgender male who's on very high dose testosterone therapy, the clitoris gets bigger and you can get cli magaly. And we don't have that much data on what that does to orgasm and arousal and that sort of thing. So I think it's a little bit of an open space, which is, exciting cuz I think there's a lot of opportunities for research and we're really trying to get some research, started. But, but we don't have. All the answers to all the questions.
Ann Marie:And are orgasm problems common? Yeah, absolutely.
rachel:Orgasm problems are common. The biggest problem with orgasm is that society has told us that women are supposed to orgasm from penetration. That is like the biggest bunch of BS that has ever been sold to society that, that I could ever imagine. And so what I always tell my male patients, and I do this all the time, I say, okay, guys.
Rub the inside of your thigh, rub it really hard for five minutes. Are you gonna have an orgasm? And they look at me. I did this with a group of high school students just last week. I said, rub the inside of your thigh. Are you gonna have an orgasm? And they started giggling and they said, no, Dr. Ruben, we're not gonna have an orgasm. I said, no, no. Really hit the inside of your thigh over and over again for 10 minutes. Now are you gonna have an orgasm? And they giggled and said, no, of course we're not gonna have an orga. So why? because it was not my penis. Dr. Ruben, like, I gotta rip my penis in order to have an orgasm so it's so close to your penis, so it's not gonna happen. I said, no shit People, right? A clitoris is close to the vagina, but it is not the vagina, and so you can penetrate all you want into that vagina. It almost never will stimulate the clitoris to orgasm for some lucky few, probably less than 10%. You know, it does. And. It's wonderful. You should have all of the pleasure that you possibly can, but for the majority of, uh, women, they don't orgasm with penetration and we have to normalize that. And so the clitoris and the penis are exactly the same thing made up of the exact same tissue and actually work the exact same way. And so if we can work to stimulate the clitoris, which is mostly internal, and that's typically either through vibration or you know, I love. Is for, for patients and all sorts of different devices out there. Orgasm should be happening as frequently, if not more frequently, than the male counterparts. It, it doesn't matter who you're, you can be alone, you can be with partners, whatever you want. But, it's often doesn't happen from penetration.
Ann Marie:And just to go back to the, hormone therapy, the localized hormone therapy, if you start that and people come into you with all the complaints, sandpaper, sex or pain outside of sex, muted orgasms, whatever can, and vaginal dryness, will it then replenish?
rachel:Yeah, it does. And it's so magical to watch it happen. And so again, it's not a, I wanna very clearly say it is not a one size fits all, which is why I love working with patients because we tinker and then people are often a moving target. If you're 45 and you're having symptoms, it may be different than when you're 52 or 62 or 72 and having symptoms.
And so we tinker and we kind of figure out what we. Of track and change to make things work as as good as possible. But yes, we see it all the time. You know, someone who has a dryness and pain with sex, you add vaginal hormones and that goes away. And then their orgasms come back and their orgasms become powerful again, and they can have them and they don't take as long. And there's all, it's not always. Just local vaginal hormones, although that is the best place to start. And then you kind of go from there and, and see what we can do. And sometimes we have to attack the brain, in the dopamine, centers. And, but it's really, it's so thrilling to restore a woman's sexuality, that, and she basically will come back and say, I feel like me. It's so magical to have women come in and say, I feel like me again. And, more gosh, to have partners email me and say, oh my god, Dr. Ruben, you have changed my life. I said, I've never met you before. You have changed my life because of what you've done for my partner. I'm, it's, I just, I get excited to go to work every day.
Ann Marie:It's great work. Now. Some women watching. Will not have had sex, may maybe married, won't have had sex for years, you know, and on sex in the city, it was a Miranda and Steve hadn't, she said, we haven't had sex in years. And I've heard that from people that I know. It seems hard to understand, but also if anyone who's had a relationship knows how these things can go and how hard they are to talk about how does that impact us at perimenopause and.
it's not, you know, it's enable this term to say use it or lose it, but is there an element to that?
rachel:I hate, I hate, hate, hate they use it or lose it. Because I think it is just gaslighting to women and horrible to say, you must have, penile penetration in order to keep going. That is absurd.
The tissue needs hormones. The tissue needs hormones. This is actually not about sex. This is about bladder and urinary health, okay? And so vaginal hormones absolutely are necessary to have a healthy bladder and a healthy urethra, and not to get urinary tract infections. And so if you are a. A nun who has never had sex before, and you are having urinary tract infections, you need vaginal hormones. Again, I'm a sex doctor. I love talking about restoring people's sexual health, but my first hat here is as a urologist, and to say this is actually not just about sex, that will improve and get better and make it possible, but this is about bladder and urinary health. So I don't care if penetration ever happens again with you and your partner. That is a biopsy psychosocial decision that is a complex one and one we can focus on. But what I do want is for patients to be able to wipe themselves without pain, but I do want them to be able to walk and wear yoga pants and, and do the, the daily activities and live the life that they wanna live. Now, if that includes a sexual life, and that could mean, I have lots of patients who have fabulous sex and don't have penetration cuz their partners maybe have a cancer or a broken. Or something where it makes it really challenging to have penetration. And they have great orgasms together and they have great sex, and they have so much fun and love. I talk to an 88 year old, a patient, I see both he and his partner, and he says to me every year we talk. And every year he says, Dr. Ruben, I'm more in love with my wife than ever. I just love her so much. I love being around her. I love the sex that we have together. And I said, what does the sex look like? He says, we just, we, we, we touch each other, we caress, we hold each other, we orgasm. So much fun. It's the best sex ever. Well, that sounds not so bad to me. Right. That sounds pretty good. And so, it's, sometimes I have to figure out how to make you have the best sex you wanna have, but also make you change your mind of what you think that should look like and to tell Hollywood to shove it, and that we can have our own definitions of what good sex is. They're still doing it. I'm still seeing shows. I'm still seeing shows with the penetration and the
rachel:Yeah, I know. It's terrible. The instant orgasm, right? The penetra, so, so there's data, right? So if a man penetrates a woman, on average, he will last five and a half minutes, forget what you watch on the porn.
On the porn channels. Five and a half minutes is average for a woman. Remember we said most don't orgasm from penetration flat out, but if they can, it's it's usually the amount of time a woman can orgasm with a partner. Forget penetration or not. It's like over 13 minutes. And so we have a problem of timing in this country and so we can't talk about penetration as being sex. It should be the whole activity. Forget foreplay, forget after play. Forget extra credit. Some people can't orgasm at all of all genders, and so it should just be. Fun and playtime and pleasure, and if you can get your mind around that then, then you can have fun and playtime and pleasure.
Ann Marie:And do we need to have orgasms? Do we need to have sexual activity in our lives to be healthy humans?
rachel:You know, I think there's data to show that orgasm has health benefits, quality of life, mood, stress reduction. We don't have much data to show that orgasm is a life and death, activity.
Although I certainly have patients who believe that, you know, it, it's really, it, it. It's often hard to think about just something that gives you joy and pleasure and that can really focus on you. And if you are someone who can orgasm, it's a great opportunity to get in your own space, in your own world and just feel pleasure and relaxation and relief. And not everyone can have that. And, and, and many people who have it and lose it are very bothered by it, and they should be. And it is something we should focus on. And so if it matters to you, It should and you. That is valuable and that is important, and that is a medical problem. If you have a problem with your orgasm, it is a medical problem. However, there are not that many doctors trained to help work up those types of medical problems.
Ann Marie:I've, I've talked a lot of my newsletter about this.$600 billion opportunity offered by menopause by this 2025 and 1.1 billion. You know, the whole thing, the gold rush that's supposed to be coming and I'm already seeing so many contraptions and things.
So I just wanted to ask your take on some of these things that we see. So first of all, before anything, how important are Kegels? Just the, the ones you do on your.
rachel:So there's some data to show that if you tell a woman to do a key goal, she does it, or a man to do a key goal. They do it wrong about 80% of the time.
And so there's something to, if I tell you to do a key goal, you're, you're kind of, you're not very good at it. And so that's where I really encourage. People to work with pelvic floor physical therapists because it's not all about the key goal. And I think we often, we, we, when products come out there, they are well-intentioned. But I think the idea that there's a one size fits all, solution is, is kind of silly. There is not a one size fits all. And so for. For pelvic health, a key goal can be very helpful to strengthen your pelvic floor muscles and make you not leak urine when you cough, laugh, or sneeze. But for someone who has pelvic pain or genital urinary syndrome of menopause, your muscles are so tight and tense that a key goal is actually going to make things worse. And so it is really important that you're not, just totally treating yourself and, saying, oh, I know exactly what to do here. Cuz some you wanna see an expert who can really. Get a personalized program for you to know your body because your body is not like anybody else's. And no matter what Gweneth Paltro says, you know, she doesn't know what's your exact story and what's going on in your life.
Ann Marie:So you see a lot of devices with apps, and of course you're like, okay, I'll get that. So you're saying go see this specialist before you decide to go get a device?
rachel:I think it's, it's help. You know, in life we have coaches for little League baseball, right? We have coaches for makeup tutorials, we have coaches for, again, this idea that you can do it all on your own.
When menopause is a very complex issue that's affecting every part of your body. You deserve expert care. And I think one of the big challenges that we have is we don't have enough providers who give expert care and who really know what they're doing, which is why I spend so much time yelling and screaming and teaching because, we need more education on these topics. We need more providers who give hormone therapy correctly. We need more providers who know what they're doing. And so there is. There is a big gap.
Ann Marie:What do you consider dangerous that you see out there? What do people need to be careful about?
So I think there is some danger in super physiologic levels of hormones, you know, there's, there's a lot of talk about pellet therapies out there, and I, I think we just don't know what's. There's not enough regulation of that market, and I would love for the pellet companies to, go to the f d A and actually be more regulated and have us be able to really look at it and study it and do the data because I don't discount that that patients often can feel good on using these types of therapies and that there's well-intentioned. Providers out there. But when you get super physiologic levels, again, you run the risk of things like endometrial cancer or other harmful things. And I think if we just studied it more, everyone would feel more comfortable or confident. We have an f d a approved testosterone pellet therapy. It works great and I feel great about, you know, using that product on male patients. I would love to feel just as good using those kinds of products on my, female patients, but we just don't have the data. And I think that. Big frustration of mine in terms of what could be dangerous. I think also we're Dan, it's a dangerous, path to tell women that everything can be done naturally and that hormones are dangerous and that you should, oh, this is a great product cuz it doesn't have estrogen in it. Estrogen is one of the best products in the world, in my opinion. It's the only essential oil out there. I think it's dangerous to tell women that everything can be done through a supplement or, or through, natural mindfulness and meditation.
Ann Marie:You do get that feeling sometimes.
How about laser treatments on the vagina? This, you're seeing a lot of this.
rachel:Let's, yeah, so again, laser treatments are a tool that can be used in treating, genital urinary syndrome of menopause. There is no better treatment than vaginal hormones. Vaginal hormones are correct and the correct answer for almost.
All people over 50, I'll say over 45 even. And if you say, oh, Dr. Ruben, I can't use it cuz I have this thing or that thing or the other thing. There is almost no patient where I will say, truly you cannot use it. Sometimes we gotta talk to your cancer doctors. Sometimes we have to have nuanced conversations. But there is almost no person on earth who I will say, no, you cannot have local vaginal hormone. Right. That doesn't mean, you know, again, there's a difference between local therapy and estrogen for your whole body, or testosterone for your whole body. It's a nuanced conversation. And so it's really important. So lasers could be helpful, you know, potentially synergistically with those therapies. Lasers are showing some promise in, helping, spark that tissue healing and, and sort of a collagen formation. That's a good thing. But I haven't seen a laser therapy that's like, oh, you don't need hormones, girl, everything's fine. Like, it's totally good. And so I think it's often we, we have these cash-based things that cost a lot of money, and you think they're the answer to all of your problems. And the answer is no. I'm, I wish it was that easy. There's no, shot or laser rejuvenation or anything that you're gonna press a button and everything's gonna be better. It would be nice and miraculous, but it's not gonna happen. And so we have to stop trying to sell women on these things, cuz they're complex issues, but that doesn't mean they don't, they have solutions. But it's not sort of a one size fits all.
ann:And whenever I interview, I tell people I'm interviewing a doctor about anything to do with menopause.
They say, should I go on H r T? What are the risks? And it's a holdover from this Woman's Health Initiative study from 2002 we hear about. But when it comes to localized the kind of hormones you're talking about, what's the risk profile? What do you tell people?
rachel:Yeah, so I, I think the idea that all hormones are safe or all hormones are dangerous.
Ridiculous, right? I wish it could be black and white and we could say yes or no. And often we're humans, we like to, we like to make things easy and say, okay, is it good or bad? Just gimme the too long, didn't read. Is it good for me or is it bad for me? And it's not so simple and they're not all the same. So I'll give an example. Let's talk about contraception, because people are more comfortable with hormones when it comes to birth control. So if I say the word birth control to you, and I say the word condom to you, Do you get the same sense of risk for each one? Do they each have the same? I in terms of Right, like side effects is a side effect of a condom the same as the side effect of a birth control pill? No. No. Right. But they're both contraception, right? They're both preventing pregnancy, but they're not the same thing. They're very different. if I say that birth control pills have a rare side effect of blood clots, does that same something you've heard before?
Ann Marie:Yes, for sure.
rachel:Yeah, so we, we've all heard that before, but yet we're all pretty like pro-birth control.
We like the idea of birth control for young people, although they can have blood clots associated with it. It seems like the good outweighs the bad. So very many millions of of women do take these therapies. And so, It's nuance, right? You can't say condoms and birth control have the same risk to them because if you said all contraceptions should have the same warning labels, then we would put blood clots on condom packages, right? Every condom package would come with a warning label of causes, blood clots. Well, that's the ridiculous concept, Dr. Rubin. And it's the same story when it comes to, hormone therapy. They're not all the same. Not all hormone therapy for menopause is the same, and they should not have all the same warning labels and black box warnings and fear mongering. That happens. And so when you take a birth control pill in menopause, guess what? Blood clots. Wait. It happens in young people, it happens in older people and probably happens a little bit more in older people. So if you give great grandma in her eighties, a hormone a, a birth control pill, she's gonna have a higher risk of blood clots. Okay, that doesn't sound good. But if you give 88 year old grandma a vaginal estrogen tablet to. To fix her urinary symptoms and her urinary tract infections. There's no risk of blood clots. It's a different, it's a different product and it has different side effects and different, risk factors to it. It's totally safe. And so estrogen, when you had the women's health initiative study, everyone feared hormones, but when you actually looked at the study, women who were on the estrogen only type birth control, cuz they didn't have a uterus. So even that birth control Yeah, they had a few increased blood clo. But they actually had a decreased risk of getting and dying from breast cancer, a decreased risk of getting and dying from breast cancer when it was just the estrogen piece. So it was actually never estrogen that caused breast cancer? It was actually protective. That didn't make the headlines. Matt Lauer did not get on TV to talk about that, but he did get on TV to talk about how dangerous all hormones are. Right. And so, so it's, the problem is it's a nuanced discussion, and I know that was long-winded because it, it really is, complicated. So for the majority of women, in their, early menopause years, so we're kind of that first 10 years where you're having the worst symptoms. Hormone therapy is incredibly beneficial, incredibly safe for the majority of people, not everybody. And works great and you can continue it past those 10 years, but it seems to be if you start it early, that's the most benefit. Now, where we're a little bit more, nuanced, that doesn't mean no one can have it is when you're 10 years past menopause. Local therapy's always safe, always good, but when it gets to some of those systemic therapies, it has to be an individualized conversation with your.
Ann Marie:I did see something on social media the other day I wanted to ask you about, because it was a, a doctor in the sexual health realm, and he said maybe it's your libido or maybe it's your partner.
What do you think about someone putting like something like that on social media?
rachel:I think it's, I think, I think thought provoking comments really are, are helpful because, and, and someone said in a conference that I was at recently and I posted this and she said, she's a great sex therapist in Chicago.
And she said, she said, is the sex you're having worth wanting? Ah, Right. Is the sex that you are having something worth getting excited over and that's on you and your partner, right? If you are not working towards making it fun and enjoyable and, spicing things up and keeping your brain excited. Why would you want that? Right? If it hurts, why would you want it? If you're not orgasming and having pleasure and enjoying yourself, why would you want it? Yeah, your partner might want it, but why would you? And so I think that's where the nuance conversations come in of, libido is not just this thing that magically happens. Sometimes it takes a little bit of work. You know, if you're gonna go on vacation and you're staying at. Really sketchy place that really is dirty and smelly and, and, nothing's working. And are you gonna have a great time? Like, you're gonna be pretty uncomfortable and you'd probably rather be at home. But if gonna stay at, a five star hotel and it's like you're being treated like a queen and it's amazing in the best place ever, well that sounds like a much better vacation. And it's not always gonna be the best thing in the world every time it happens, but how can you create these moments and, work towards, you know, a good time because you deserve pleasure. I think that's the key is, you have to understand that your pleasure is, it matters and it's important, but it may not look the same way as your partner sort of sees it.
Ann Marie:Well, I'll just leave asking you what would you like to see, what's not being researched? For women that you would like to see as supposedly we're breaking through the patriarchy and all these things are changing.
What needs to be studied first and foremost?
rachel:Unlimited. There is unlimited need there. I wanna stop saying to patients, this is a data free zone. We need money and research dollars and fellowships that train, Providers and sexual medicine providers. I did the only fellowship in the country that even acknowledges women's sexual health.
And it's a urology fellowship that does, all gendered sexual medicine. And there's one spot a year. Okay. One spot a year. And there's not even anyone doing it next year. And so we need to train the next generation of providers. I just started a, volunteer research group where I have a hundred, Students and residents and people who are just interested in doing research projects. And we meet once a month and we're just coming up with research ideas to find ways we can do more research and, and, and, and get more out there. And we've got, you know, four main things we're working on. One is clitoris research, vulva dny or pelvic pain research. We'd. See just more sexual medicine research, for transgender populations, and really a more education and advocacy work that we would like to see done. And so, that's just a ragtag group of volunteers that are coming together to, to really try to get a more work done. But we need more, I mean the, the work on clitoris and orgasm is sort of a, totally open space. Like we, we we're trying, we just submitted research on. Clitoral adhesions, that by treating them you can improve orgasm arousal and decrease pain. And the research was rejected by urology group of the urology meeting and a gynecology meeting. and so, they don't wanna hear about it. And so the urologists and the gynecologist don't wanna hear about it. So we're gonna keep yelling and keep screaming, get all these things published, and, and continue this work. This doesn't get n i h grants. This doesn't get billions of dollars of funding and it's a problem. And so, we have to keep yelling and fighting and talking to anyone who will listen. So thank you for having me. Cuz you're listening. Thank you so much. I really appreciate it. I know you're busy. Go heal some some people. Thank you. Thank you.
Ann Marie:Thank you so much for joining me. If you like this conversation, I hope you'll check out some of my other interviews on the Hot Flashing Podcast, subscribe, give a rating, maybe a review, and come back for more next week. Hot Flash Inc. Was created and is hosted by Annemarie McQueen, produced and edited by Sonya Mac. The information contained in this podcast is intended for informational purposes only, and is not intended for the purpose of diagnosing, treating, curing, or preventing any disease. Before using any products referenced on the podcast, consult with your healthcare provider, read all labels, and he all directions and cautions that accompany the products. Information received through the podcast should not be used in place of a consultation or advice. Care provider. If you suspect you have a medical problem, ie. Menopause or anything else or any healthcare questions, please promptly see your healthcare provider. This podcast, including Annemarie McQueen and any producers or editors disclaim any responsibility from any possible adverse effects from the use of any information. Contains herein opinions of guests on this podcast. Are their own, and the podcast does not endorse or accept responsibility for statements made by guests. This podcast does not make any representations or warranties about a guest's qualifications or credibility. This podcast may contain paid endorsements and advertisements for products or services. Individuals on this podcast may have direct or indirect financial interest in products or services. Referred to here in this podcast is owned by Hot Flash, Inc. Media.
