#348 ‒ Women's sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.

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Rachel Rubin is a board-certified urologist and one of the nation's foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women's sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women's Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women.

We discuss:

• Rachel's training in urology and passion for sexual medicine and women's health [3:00];
• Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women's health and quality of life [5:30];
• Why women have such varied responses to the sharp drop in progesterone during the luteal phase and after menopause, and the differing responses to progesterone supplementation [14:45];
• The physical and cognitive health risks for postmenopausal women who are not on hormone therapy [17:45];
• The history of hormone replacement therapy (HRT), and how misinterpretation of the Women's Health Initiative study led to abandonment of HRT [20:15];
• The medical system's failure to train doctors in hormone therapy after the WHI study and its lasting impact on menopause care [29:30];
• The underappreciated role of testosterone in women's sexual health, and the systemic and regulatory barriers preventing its broader use in female healthcare [35:00];
• The bias against HRT—how institutional resistance is preventing meaningful progress in women's health [46:30];
• How the medical system's neglect of menopause care has opened the door for unregulated and potentially harmful hormone clinics to take advantage of underserved women [53:30];
• The HRT playbook for women part 1: progesterone [57:15];
• The HRT playbook for women part 2: estradiol [1:05:00];
• Oral formulated estrogen for systemic administration: risks and benefits [1:13:15];
• Topical and vaginal estrogen delivery options: benefits and limitations, and how to personalize treatment for each patient [1:17:15];
• How to navigate hormone lab testing without getting misled [1:24:15];
• The wide-ranging symptoms of menopause—joint pain, brain fog, mood issues, and more [1:31:45];
• The evolution of medical terminology and the underrecognized importance of local estrogen therapy for urinary and vaginal health in menopausal women [1:37:45];
• The benefits of vaginal estrogen (or DHEA) for preventing UTIs, improving sexual health, and more [1:41:00];
• The use of DHEA and testosterone in treating hormone-sensitive genital tissues, and an explanation of what often causes women pain [1:50:15];
• Is it too late to start HRT after menopause? [1:56:15];
Should women stop hormone therapy after 10 years? [1:58:15];
• How to manage hormone therapy in women with BRCA mutations, DCIS (ductal carcinoma in situ), or a history of breast cancer [2:00:00];
• How women can identify good menopause care providers and avoid harmful hormone therapy practices, and why menopause medicine is critical for both women and men [2:06:00]; and
• More.

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