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

In this episode Dr. Mary Claire Haver is joined by Dr. Rachel Rubin, a board-certified urologist and nationally recognized expert in sexual medicine, fellowship trained in both female and male sexual health. As assistant clinical professor of urology at Georgetown University and former education chair of the International Society for the Study of Women's Sexual Health, she brings unique insight into the stark disparities in how sexual dysfunction is treated across genders. Dr. Rubin founded the Sexual Medicine Research Team, and her advocacy work has been instrumental in changing FDA labeling on hormone therapy and advancing the American Urological Association Guidelines on genital urinary syndrome of menopause.

During the conversation, Dr. Haver and Dr. Rubin explore the intersection of menopause, hormones and women's sexual health, revealing why most doctors, including OB-GYNs, receive virtually no training in sexual health despite sexual dysfunction affecting millions of women. Dr. Rubin explains how men's sexual health benefits from 27 fellowship programs while women's sexual health has only three, and why erectile dysfunction research receives billions while female orgasm research gets nothing from the NIH. She breaks down the complete anatomy of the clitoris that most medical professionals never learned, explaining why understanding this matters for surgical outcomes, pleasure, and treating conditions like vulvar vestibule pain that affects penetration, tampon use, and pelvic exams. Dr. Rubin discusses how the vulvar vestibule, the hormone sensitive tissue surrounding the urethra, becomes a source of pain for many women during perimenopause, on birth control pills, or postpartum due to low estrogen and testosterone.

Dr. Haver and Dr. Rubin also address genital urinary syndrome of menopause, or GSM, and why vaginal estrogen is critical not just for sexual function but for preventing urinary tract infections and sepsis. Dr. Rubin explains how vaginal estrogen could save Medicare up to 22 billion dollars annually yet remains dramatically underutilized because doctors dismiss vaginal and urinary symptoms as normal aging. She introduces vaginal DHEA as another FDA approved option that provides both estrogen and testosterone benefits locally, particularly helpful for women on aromatase inhibitors or those who need additional androgen support for the genital tissue. Dr. Rubin walks through the five-ingredient menu of hormone therapy, including systemic estrogen, progesterone, and testosterone, plus local vaginal hormones and targeted vestibule treatment when needed. She discusses the role of pelvic floor physical therapy in addressing painful sex and bladder health concerns.

Dr. Rubin discusses medications and their sexual side effects, from SSRIs causing delayed orgasm and genital numbness to birth control pills potentially lowering libido and causing vestibule pain by suppressing testosterone. She explains how spironolactone, finasteride, and even GLP-1 medications can impact sexual function in ways patients are rarely counseled about, while men routinely receive detailed discussions about sexual side effects. The conversation covers FDA approved medications for low libido in women, including Addyi and Vyleesi, that work on dopamine pathways in the brain and genitals to improve not just desire but arousal, orgasm, and lubrication. Dr. Rubin shares why these medications remain unknown to most women despite being available for years, and how insurance companies create barriers by requiring women to fail marriage counseling before approving treatment.

The episode concludes with a discussion of how relentless advocacy finally removed misleading black box warnings from hormone therapy labels after 20 years. Dr. Rubin explains why the label never should have existed in the first place, how the FDA required no advisory panel to add the warning but extensive bureaucracy to remove it, and what changed when advocates got loud enough. Whether you're experiencing painful sex, low libido, recurrent UTIs, or simply want to understand how hormones, medications, and life stages affect sexual function and menopause symptoms, this conversation provides the evidence-based information and validation that women deserve.

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