The Ultimate Guide to Women’s Sexual Health, Hormone Replacement Therapy (HRT) & Menopause

What you're about to listen to is the single most important episode that we've ever done about women's health.

I'm talking jaw-dropping information about hormones, menopause, birth control, pregnancy, UTIs, and women's sexual health. Today, I'm joined by one of the world's most highly regarded, trusted, and renowned urologists and sexual health medical experts who says, "Stop, gaslighting yourself." You deserve better when it comes to health care.

You deserve to be listened to, treated, cared for, informed, and empowered through every single change happening in your body and every symptom that you may feel as your hormones go up and down.

“I mean, how many times do you have to explain away the discomfort, the dryness, the pain,”

and say, "Oh, it's so big deal, I'm fine." Don't worry about me. I know, I just don't feel like myself, I'll push through. Just a little stressed, I know, I know, I know, I know, I'm tired, moody, anxious. Well, I'm gonna tell you something.

I've said every single one of those things, and I bet you have to.

But after listening today, you will never say those things again.

I hope you not only listen. I truly hope you share this with every woman you know. With your daughters, your sisters, your friends, your partner, your mom, your grandma, your aunt, because it will not only change your life. What she learns in this episode might just save it.

“Hey, it's your friend Mel, and welcome to the Mel Robbins podcast.”

I am so happy you're here. It's such an honor to spend time with you and to be together, and if you're a new listener, I just want to take a moment and welcome you to the Mel Robbins podcast family. And I'm thrilled that you're listening to this particular episode, not only to learn for yourself, but that you're also listening on behalf of all the women that you care about

in your life, because I want you to consider this episode a life changing, and maybe even a life-saving resource that you can share for free with women in your life. Our medical expert today is going to 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.

She's going to answer all of the questions most of us are searching online, alone, secretly, because let's face it. We're either afraid of talking to our doctors about it, or we're too embarrassed to even say the word vagina out loud. Dr. Rachel Ruben is a board-certified urologist and one of the nation's foremost experts

in sexual health. She is one of only a handful of physicians in the United States with a specialty in sexual medicine for all genders, who is also training thousands of doctors around the world, about prescribing hormones correctly. She is a clinician, a researcher, and a passionate educator, who teaches doctors around

the world how to properly diagnose and treat sexual health conditions that are often overlooked or dismissed. She is the director at large for the International Society for the Study of Women's Sexual Health, and she's served as an associate editor for the Journal of Sexual Medicine Review and the Video Journal of Sexual Medicine.

Today, she's here to teach you what everyone needs to know about sexual health, menopause, hormone replacement therapy, and out-of-take care of everything down there. So please help me welcome Dr. Rachel Ruben to the Mel Robbins podcast. Dr. Rachel Ruben, welcome to the Mel Robbins podcast. My gosh, I'm so happy to be here. This is a dream come true.

Well, it's a dream come true for me, too. And by the time you're done listening, I know you're going to say to yourself, wow, Dr. Ruben 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 going to cover, much of which you will

have never heard of your life before.

Whether you are going through puberty, whether you are going through childbirth, parent-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. Oh, I'm here for it, your best-damn life, let's go, Dr. Ruben.

My mission is fully that I believe when you give women information about how their bodies

work, they make excellent health care decisions for themselves.

“And I truly believe when they have good health, good mental health, good community, good”

support, they are masterful at optimizing their own lives to whatever degree that they want them to. I love that. I love that. So Dr. Ruben, we're going to cover so much, but I think where I want to start is what

is a sexual medicine doctor versus a urologist? Yeah, it's a great question. So urologists are genital urinary 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 check, 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, I think Viagra think erections like that's 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. This is brand new information, I'm like almost embarrassed to admit it, I literally think

primary care gynecologist, primary care gynecologist.

“And that's what I find every day when I talk to patients, isn't never comes up.”

Yes. 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. Today, today in 2026, so it's not like, oh, I have a bad doctor, no one taught them. So how are these 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. What are the things that a lot of doctors say to women in particular that aren't true or

that are wrong in this category of sexual health? Oh, drink a glass of wine, if you have low libido or have pain with sex, read 50 shades of gray. 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, gas lit, told they didn't have anything wrong with them, told them they couldn't see the problems, so it must be all in their head. Wow. What are 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. Any time you find yourself thinking or even telling yourself, oh, this is just how it is getting older. 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, ah, 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? 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 for miraculously for people and so it is so important

cough laugh or sneeze, that they don't get their 10th UTI without asking, hey can I actually

prevent this from happening or they see the right clinician because just because it's someone you've worked with for 20 years doesn't mean they're up to date on what's going on with you now. Well, that makes so much sense. Dr. Rubin, 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 is every 20-year-old woman whether she's sexually active or not in that decade?

“What do you need to know during pregnancy? What do you need to know during perimenopause,”

menopause and beyond? So hormones are not good or bad right or wrong. They shouldn't come with emotions and feelings and stigma. Okay, they just are. 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 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 for like made. So kids have no 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 25, they're not in significant which helps their bones and girls right when they have in this pubertal stage, the ovaries are doing these wild fluctuations and they are unpredictable and I love talking

about perimenopause because 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 hold space for it. And so what's happening is estrogen goes up, progesterone. If you ovulate the shell of the egg makes progesterone throughout the cycle to testosterone is made, we think it peaks during

“ovulation because that's what gets aerobito going, makes you want to make a baby. And so that's”

fluctuating and sometimes it stabilizes. If you're lucky, you get regular irregularity. So means every 28 days you're kind of used to this weird 28 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 50,

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 in your estrogen might get to 150. Maybe 300. 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 to start all over again. So you are you 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 3000. Okay, an estrogen of 3000 for about nine”

months and then as soon as you have the baby, that 3000 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 breast feeds 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 wearing your life cycle, you are, the more your symptoms start to make sense. I'm breastfeeding and I'm having hot flashes all the time. My sleep is really disrupted. Yes, the baby's crying, but my brain fog, nobody remembers their birth. You know, because you have so much brain fog because your estrogen just went from 3000 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 35. Okay, around your 30s. Your testosterone starts to drop precipitously. Okay, so 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 sperm, or lactone,

or 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 holds to zero. And menopause is a castration event where your hormones just turn off,

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 or you have terrible PMS. Or if you have tear, 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 us the updated version. 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. Hormones are a part of this story, yes. What is one of the big things that doctors or people think they knew that's actually wrong?

Well, that we treat all UTIs just with antibiotics, that's one thing and that every,

“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. Wait, you can get UTIs or hormone changes? Yes, absolutely. And it's so common. And in fact, that we, so any kind of hormone fluctuation that happens in your body will affect your genital and urinary health. And so when you play with hormones, there are consequences, sometimes good and sometimes bad. So people who 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, anastoresaltamox if in those types of things. Perry menopause and menopause can increase your risk of UTIs drastically. Okay, this is a issue called the genital urinary 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 micro dose

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 publish that we could save Medicare between $6 and $22 billion a year. I don't even know how to interview you because my mouth is on the floor right now. I just want to make sure I got that. So any kind of hormone fluctuation or hormone change or taking hormones. So whether you're talking about somebody in their

teens or twenties 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 and safe 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. Yes.”

Oh my god, I've never heard this before. So it's really important to 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. 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 tenth 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 age person for every person with every medical problem with a microdozed 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 and we advocated for about seven years, we advocated for the American Neurologic Association to publish guidelines on this exact topic and so we publish those guidelines in 2025 is my proudest achievement and in those guidelines it talks about these symptoms of you know the hormonal shifts that happen not just in menopause but in breastfeeding and breast cancer in birth control pills in any type of of hormonal type of medications that

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 talked”

talk your doctors this no one ever talked about it publicly because 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 because you just go to your gynecologist and I'll be honest your gynecologist is busy doing life saving work for pregnant 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 last year there were warning labels on the vaginal hormone products okay and 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 grass roots 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 because it's really I'm really proud of it I got to look at the FDA commissioner and I said your box 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 and health and human services and announced that they were removing the box label that box labeling your doctor your family doctor

your kind of colleges your neurologist they would give you this medication and then the ladies would take it home and they say oh my god this is scary this says it's going to kill me 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 non-stop at every angle both through the FDA to patients every day to teach clinicians every day because

“each arm of that is so important to save those lives I am I just cannot believe this conversation”

Dr. Ruben I have so many more questions but I want to hit the pause button because what you just said made me think of two friends of mine who are dealing with this right now and I bet you have people in your life that are coming to mind so let's give our sponsors a chance to share a few words and I want to give you a chance to share Dr. Rachel Rubens expertise and this life-saving and life-changing information with women in your life your mom your sister your friends your daughters

everybody deserves to know this and to have the medical truth and don't go anywhere Dr. Ruben is so much more to teach us when we return to stay with us welcome back it's your friend Mel Robbins I'm so grateful that you're here we are learning about what every woman should know about menopause HRT, vaginal health pelvic floor issues and the very common hormonal changes that happened to us throughout our lives from the extraordinary Dr. Rachel Ruben so Dr. Ruben let's just

jump right back in I mean I don't even know how to summarize what we're talking about because we're talking about hormones and sexual health and UTIs and just your health in general and you were just

explaining something I never knew which is GSM and the fact that women of all ages get UTIs

because of changes in hormones due to birth control breastfeeding like we all thought this is due to sex it's due to hormones and that there is a very safe and very accessible preventative treatment or a vaginal hormones that can help you prevent this it's truly old news that needs to get

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 thought to get these guidelines created because you cannot argue with guidelines by the American Yourological Association first of all thank you for all of that work and thank you for explaining that and I want to be sure that we don't move on until we've completely unpacked this 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 seeing the same thing over and over and over again basic stuff GSM genital urinary syndrome of menopause is what happens to the vagina to the vulva to the bladder to the urethra 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 you probably remember when you used to

change their diaper it was teensy tiny it didn't look like grown-up genitals it looks like baby

“genitals right that is no hormones okay that's what happens when there's no hormones very thin it's”

very fragile yes they pee their diaper all the time oh yes you put that diaper cream it's a

visual anyone who's changed the diaper they they know this right 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 labias 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

“parry menopause happens or other things like breastfeeding or birth control pills or so this”

this gsm can affect a 20 year old it can absolutely it's your own birth control absolutely okay 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 as a healthy microbiome you start to lose that acidity the pH starts to rise bad bacteria start to grow the good bacteria start to shrink use can see 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 menora those inner wings can start to disappear actually because women don't know that their genitals are changing in response to changing hormones but there's so much hope because with micro dosing 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 wait what hormones have to do with frequency urgency and leakage because the whole environment when it has hormones it's less twitchy it's less irritated it is the response to the

dryness the thinnest irritation where your bladder is just like oh I'm not feeling great I'm not feeling my best self right now and so the hormones fix the bladder as well and so it is truly it's so wild how simple and easy this is it's used to be called vaginal blindness a trophic vaginalitis so this is kind of seeing this like oh yeah it's a little dry down there okay old lady here's some lubricant oh here's some moisturizer no no this is urinary tract infections this is

yes help people your experience oh my god when I was in my mid 20s I started getting chronic UTIs

was your birth control why we thought it was because I was having sex with my boyfriend but it was probably a combination of both yeah and I it became such a problem that I had two hospitalizations where the UTI would start I would think that the antibiotics got it but meanwhile it was traveling up to your kidneys to my kidneys I would spike a super high fever and then end up like with a UTI that had gone to the kidneys and then when I had kids oh my god once I had kids it was like

two decades of cycling through many perimenopause where I would get so dry and so irritated I've had constant issues with leaking and with urgency and it was just called vaginal dryness

and so I would treat a UTI with an antibiotic I would drink cranberry juice I would

slap some A&D on with a pad in my underwear in order to kind of get through it and I would just grit and burn it can I just say on behalf of all of my colleagues I'm so sorry that you were not treated to the full extent of our knowledge because we have completely not taught medical professionals

“the underlying reasons of why this is so important well I want to just make sure I understand”

what you mean by vaginal hormone supplements and that this is both something you can just do as part of your protocol to keep your sexual health and the hormone balance of your vagina and your urinary tract imbalance but it's also how you treat it so this is really important because it can be part of your hormone regimen okay 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 still well I learned like I'm weren't a patch right now and I popped my ass my my progesterone pill last night do you put anything vaginally like I just we're about to change your life thank God make it like I need some

“leave this oh my God I need some testosterone do what I think so we're gonna have some fun because”

it's really important because 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 are have going on is not rare and so it is so important and we wrote this in our guidelines the American Erologic Association we published guidelines on the genital urinary syndrome of menopause in 2025 my favorite guideline statement is number 11 which is people on hormone therapy still should be screened and treated for the genital urinary

syndrome of menopause and we should be giving vaginal hormones so if you have any symptoms I'll ask do of any symptoms of urinary frequency urgency leakage UTI's dryness pain anything like that I don't have any leakage because I actually ended up getting water surgery yeah it got that bad and occasionally dryness yeah frequency I go I go the path for more than I'd like to go women just put up with what's their normal and so when how often should I go the path when I even know

when we add vaginal hormones to your routine and about two to three months you're going to 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 really I you know what I'm going to admit something and the team will probably out me on this I bet I use the bathroom here eight or nine times a day yeah it's a lot and that's a symptom of GSM potentially absolutely really yeah holy I didn't even know that this

was something that we could change let's try the reality is is adding vaginal hormones has no downside

literally no downside takes about two to three months to maximally get your tissue this is true rejuvenation by the way all that adds for vaginal rejuvenations are crap this is real rejuvenation because like a plant needing water think of a dry cracked hungry plant you give it water and it thrives and so this is what vaginal hormones are to this tissue so it takes about two to three months to maximally prevent those UTIs and to fix those symptoms and there are other things to do as

“well I'm not saying this is the only thing you have to do but it is like sunscreen it is the”

foundational element this is the life-saving therapy that is going to keep the tissue as healthy and as flourishing as possible wow Dr. Ruben I am so grateful that you came to our Boston studios you know what you're explaining is making me feel so seen it's making me understand my body differently I cannot wait for my two adult daughters to hear everything you've just explained

empowering way and if you're listening right now and saying wait oh my gosh this is me this is

“exactly what I've been experiencing do not keep that insight to yourself be generous share Dr. Ruben's”

expertise with your sister your mom your friends your colleagues your daughters because this information could change your life don't go anywhere Dr. Ruben and I are going to be right back after this short break to stay with us what if I told you you could get 23 grams of complete protein in a three-ounce shot that fits in your pocket it tastes delicious it has no artificial dies no artificial sweeteners or flavors and it's only a hundred calories 92% of those calories

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first order at purginessprotein.com when you use code mail plus there's a 30-day moneyback guarantee here's to your health welcome back at your friend mail robins and today you and I are learning from Dr. Rachel Rubin who is sharing something incredibly empowering your symptoms are not random and they're not

“something that you have to live with Dr. Rachel Rubin is here sharing what every woman should know”

about menopause, HRT, vaginal health, pelvic floor issues and the very common hormonal changes that happen to us throughout our lives I'm so grateful that you're listening and that you're sharing

this with the women in your life so let's just keep going with where we were I love if you're listening

there's all kinds of things on the table now it's like you dumped your medical person, oh gosh my medical bag okay so we have can you see any of this I can I'm going to hold that for you're holding up I'm going to hold it up okay so here we have some vaginal pH paper and actually you can get vaginal pH paper on Amazon okay 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 or 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 look at the pH and it's not if it's dark blue I'm like wait man are you really using this do you have an infection that's explaining why the stuff isn't working or you're using enough

of the thing that we prescribe to you so this is something of vaginal pH strip you can buy on Amazon you can have it can do this right now and see like if you need and you can see if like this is why you're getting your anary tract infection wow 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 we really want to consider an underlying hormonal cause does that make sense?”

Yes makes a lot of sense so vaginal hormones are microdosed 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 70 year old woman on no estrogen therapy her estrogen levels are zero okay zero if she uses any of these vaginal hormone products her estrogen levels still stays around zero wow they may blip up to like 20 for a couple of hours

the data shows by the way your husband's estrogen is 25 so it blips for a couple of 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 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 dollars okay 13 dollars this

tube of cream will last you about two and a half months so that means for about seven dollars a month you can prevent UTIs by more than half and who do I get that from so right now you need a prescription but the head of the FDA said he's interested in looking at making vaginal estrogen over

doctor and there's a chance your doctor doesn't know how to write this prescription so the

guidelines which will link to 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 dollars a tube can save your life

if you don't like creams and so many women don't like to book 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 it's 10 micrograms like which is a tiny dose of extra dial 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 now if you really want to set it and forget it they make a ring

this is called an E string 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 or dementia in the nursing home 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 her husband brought her to see me she was on opioids

“because she was in so much pain and she couldn't sit and I examined her and I said I think this is just”

GSM I think you just have genital urinary 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 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 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 it's a very very common story and a ring like this and one appointment could change the quality of their life and it's

so important 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 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 and a nursing home it's the same treatment if you had been on your birth control I probably would have convinced you to get a hormonal IUD which doesn't typically cause the problem they're remarried I actually got one yeah yes and then I didn't have issues for a while yeah that's why why so

the the merena doesn't shut your so it doesn't change ovulation okay so it's a hormonal IUD but it's a progestin and it's a very microdosed amount of progestin so it doesn't go through whole body it just coats the uterus to keep the lining thin so that you don't implant and and have a baby I'm not a kind of colleges that's the best I can do as urologists but what it doesn't do what birth control does is it turns your ovaries off it shuts down your ovaries and it adds back

high doses of fake estrogen and a fake progestin it doesn't add back testosterone every woman

“on a birth control pill has a low testosterone state and and that's a problem because remember”

the genitals are full of testosterone receptors and so with throws off your microbiome which is why you had pain with sex or you or the UTIs and all of these issues around sex right because it's a sexual organ so an IUD right doesn't your ovaries now are making testosterone again they're

and that's why you stop getting UTIs wow you mentioned your mom yeah I would love to tell

“this story 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 she didn't quite see herself the way that everybody else saw her she really wasn't superhero and my mom um after COVID she developed a lung condition 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 happy to do more so she decided and her doctor's 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 didn't go well and she was in the ICU for about six months okay 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 because my mom is immunocompromised her immune system is off she is at risk of getting a urinary tract infections she's got a catheter in place she's I'm at urologist we're working on these guidelines

I know that she could die of uro's sepsis very quickly and I said I'd like to start her home dose a vaginal estrogen and they looked at me like I was insane they said little girl don't you know your mother's very sick they 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 this it 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 your 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 because 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 show 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 because what's happens if 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 well we know is that every week the team changes and we had to do it all over again oh my god and so it gave some something for my dad and my brother to advocate it gave them something they could control yeah 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 going to 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 my mother passed in November now it's so beautiful about this story actually she passed on my tenure wedding anniversary 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 what right oh my god you're going to make the right they did it on your mom's birthday no it was my mom's birthday but again this is the university university 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 like the warning label

no longer exists it never should have existed and so it was so incredible to get to have that story

all of that but she's up to somewhere what's her name Carol Ruben yeah and so she's somewhere up there you know helping with all of this stuff what a beautiful beautiful 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 honestly the”

the movement that's been happening the interest in this the guidelines coming out the labels getting changed the the ground swell of grass roots women standing up and saying no more it's so beautiful it's so overwhelming and I I just in the world which is a very scary and wild place right now to see these glimmers of hope to see that when you take action and you work in community and you get loud about something you believe in and you actually see things change again taking

action is what gives you hope and I tell my patients that every day is that we keep taking action we show up we get loud it's truly remarkable and and I to be a part of this has been

I mean I have no words right it just really is absolutely incredible you know you've shared

so much about this topic of GSM and vaginal estrogen and just so it is very clear who exactly should be on vaginal estrogen dr. Ruben yeah so there's no one who can't have vaginal estrogen 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 and if you have any urinary symptoms frequency urgency leakage any pain with sex, trinus 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 bear there is no data to show harm in these parts in fact a paper came out two years ago that said 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 less mortality so dying less if you use vaginal hormones then if you don't they're 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 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 mosh on 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 too this tube of cream a generic tube of extra dial cream can be as little as $13 a tube cash price without insurance so they are now accessible and so 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 and if the person who's listening is not in parry menopause or menopause yet they're younger yeah still candidate for vaginal so if you're breastfeeding we actually published I have the greatest research team in the world you have a good team Mel you have heard about

your team you have a great team I have an incredible this I started at grassroots research group

we published in the biggest ogejuian journal last year on gsl the genital urinary syndrome of

“lactation the fact is when you are breastfeeding you're in menopause and every kind of college”

just knows this but they forgot to tell all of us and they forgot to tell us that actually vaginal hormones were safe and so gsl are the same thing right genital urinary syndrome of lactation so when you have a breastfeeding patient or 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 safer 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

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 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 a couple years I don't know five or six years old now maybe there's something going on there I don't

like I just assume okay well this is just something I live with 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 and you

“say the thing here's the thing about it is that it feels like this thing that what am I going to”

do making appointment to go to a yearologist what am I going to do go go to my gynecologist because who's got time for that and is it even an issue or is it just like my body and and when you said the thing about like grabbing it your pants or you know feeling a little dry your things feel a little uncomfortable like is this even an issue or is this just how things are you know what I mean and that's the challenge because I'll be honest medicine is not meant for people because if you

come to my office and we only have 10 minutes which is what most doctors office visits are and we sit down for 10 minutes do you think I'm really going to get to know you Mel in 10 minutes I could be the smartest doctor in the world do you think I'm going to know or it's going to 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 going to be 1 2 3 4 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 accessible way but this idea of your support system matters how you learned about sex matters 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 because you

don't even know that there's someone who would listen and so that's what we're trying to change this idea if it matters to you there is someone who it matters to like 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 because you don't always have the space for 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 I 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 doctors 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 and but you know what we do have we have you and so we can go to your website and we are at a 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 and how to prescribe it 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 or daughters or mothers or grandmothers or sisters you're empowering us to be part of the positive change that needs to happen when it comes to women's health. 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 want to 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 birth control pills and spurnal lactone for her acne.

What hold on a second birth control pills and that medication for hormonal acne? Yes.

Which I have two daughters in their 20s. 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

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 where remote work from home because I am so afraid of being in a place with urinary

“pain and planning my whole life around it. Well here's the thing that I think is really important”

and I think it's important because in your 20s as a woman and your 30s you just kind of 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 shugging 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 going to get. It's shut now we need more

data on using these products in people young people but the reality is you won't hurt anybody.

You're not going to 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 an over a million patients with Medicare with a diagnosis

of a symptom of GSM so frequency urgency leakage UTI vaginal pain any of this one you have a one symptom which means you have UTIs based on hormone fluctuation yep you had a symptom of GSM only 9% of patients were given a prescription 9% so other than being very effective in preventing UTIs what else does vaginal hormones do for a woman of any age yes so besides preventing UTIs it's essentially biagraph for women why do you call it that because it helps with sexual health it

helps so biagraph 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 a rousal vaginal hormones help with a rousal 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 biagraph because it truly is but actually people don't know this but cialis which is biagraph's cousin

we give to men all the time for urinary symptoms frequency urgency things like that 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 biagraph 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 hot 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”

in disagrees with me which is so wild and yet women don't 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 that you know because that sounds like it's cracking and bleeding

like what is enough to affect just like thinking about it 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 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 people with any history and so um or college student or high school student attending constant UTI issues and that's where we really need to get the

explain a little bit about like how the how hormones like I'm still trying to understand how

“hormones impact like peeing yeah and and infections does that make sense like I I kind of feel”

kind of dumb that I don't know a lot about this but to me I would never think that hormones have

anything to do with the amount of times I got the bathroom whether or not I've trouble going the bathroom how how is it connected yes so the bladder and the vagina are very close together and they are filled with estrogen and testosterone receptors so they are constantly 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 fluctuates 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 dyspiosis meaning the the the right culture invite 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 you're partner ejaculates inside of you well 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 because acid base big basic material and so that also then throws off your microbiome even more can I ask a question please okay is there testosterone and so um not that's a great question actually I don't think so okay

so we're just dealing with like just that like okay just the fish okay so just the fish yeah it's the pH as the pH and because you're not a super question is a fabulous question and and because pH is one of the things that hormones help regulate yes and when the pH gets whacked regardless of whatever age you're in it screws up the microbiomes of your vagina of the urinary tract which makes you more prone to infection right am I tracking correctly you're tracking correctly

so if anything's off whether it's pH or hormone imbalance or your on-birth controller acting medication or your breastfeeding and that kind of wax your hormones period effect your microbiome which makes you more susceptible to urinary tract infections if and so again more dryness or dryness which feel okay this is where it's very interesting sometimes it feels like you have a urinary tract infection but actually just because you have pain burning and irritation oftentimes it's not

an infection what is it it's the dryness and the scrappy rug burn from basically something

imbalance hormone imbalance from rubbing against right if sex is a contact contact sport right sex is a contact sport so if you have this hard rigid thing or a device or fingers or whatever it is rubbing against think of a sunburn think of irritated dry uncomfortable tissue guess what's going to happen it's going to hurt it's going to burn it's going to be irritated and so we see so many people who think they have UTIs and they don't even get examined and no one asked

some questions or they just go to urgent care and we throw antibiotics at them and we've lost the art of doing a physical exam on people that's a whole other mission of mine is get people to know how to examine genitals but oftentimes it's not actually a UTI it's pain from the abrasions and the irritation from the act of intercourse itself wow and your hormones have a huge role to play in all of that yeah and keeping the tissue strong and supportive and lubricated and thick and able

to withstand the high intensity sport of sexual activity 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 this is why we're so excited about the interest in this this is

“why I leave my children in 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 there's no money in this this isn't like there's no this is truly like the public service announcement

with science that we have always had we the 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 that caused stroke blood clots heart attack which was zero percent true for all hormones let alone micro dosing 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 and

“we're watching channel everything and then they show notes that's why I can't be quiet I'm glad”

you're not Dr. Rubin can you talk about hormones and HRG I love talking about hormone therapy I I it was so blessed with mentorship and mentorship I this is why I mentor so much because it truly 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 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 I don't know if you've ever seen an NIH press conference I certainly haven't seen anything else making 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 caused breast cancer and cardiovascular disease and we're halting this study early well then the paper shows up at

all the done this is before social media so the paper shows up at the doctor's offices this was a 2002 I believe the women's health initiative which is what the study was called 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 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 overnight hormone

prescriptions went to zero 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 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 caused 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 testosterone it had nothing to do with to do with modern day hormone therapy 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 no cancer risk no breast cancer risk that was published on so this one study changed the course in general just a study it was the way the media reported it and the breaking hysteria that

it created hysteria and for two decades it was just believed that HRT was dangerous and you shouldn't do it and it's going to cause cancer in all this stuff and so millions and millions of millions of women who would have benefited whose quality of life would have improved we're 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 yeah and that 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 tragedy and this is an American tragedy actually a world tragedy the tragedy is not only

who never learned how to write prescriptions or ask the questions ask any doctor you know we get

“no training in the data is very clear on this we get no training in medical school we get no”

training in our residences that's even gynecology and primary care where you would expect training forget the orthopedic surgeon who's dealing with the fractures or the neurologists 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 used 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 going to 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 neurologist you can do this as an ER doctor as a primary

“care doctor as a gynecologist and so I I think my my thesis statement of our work today is there”

are no grownups coming to save the day okay there's no grownups we are the grownups and we have to roll up our sleeves and do the work ourselves sometimes well I think one of the thing that is incredibly fascinating about what you've what you've been teaching us is that if you if you're you know female you either go to a primary care gynecologist I don't even think about going to your your yourologist 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 and that makes perfect logical sense melt 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

intended 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 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 well I'm sitting or even just thinking about the fact that after I had my daughter soya I had severe postpartum

depression nobody even considered estrogen and hormone therapy as part of like maybe something that we should be talking about and this is actually where it gets even more okay so I'm going to tell you two stories that are going to make you really angry story number one is there are FDA new FDA approved medications for postpartum depressions they are based in progesterone based therapies okay they are based in hormonal therapies I started a course that it's online to people

can take it whenever they want of how to prescribe hormone therapy and I had psychiatrists pour into my my DM saying well my mouth practice insurance said I wouldn't be covered if I prescribe hormone therapy I said what are you talking about mental health is so helped with hormone therapy you are crazy for not learning hormone therapy if you also think about it like just think about PMS and the ups and downs of your moods and the fact that all of the symptoms around PMS whether it's

moodiness or it's cramping or it's dryness or it's bloating again so for you thinking that all your care should be by gynecology who also don't know how to prescribe hormone therapy I mean some do and if they take an extra training where are the psychiatrists where are the neurologists where like like this when you go have depression you go to that person not so so it's a nightmare

“we're living in a nightmare because not enough clinicians know why this is important so one good”

piece I want to say one piece of hope because this is actually beautiful the head of the gynecology association it changes every year or two okay happen to be this amazing doctor from Yale old school male gynecologists who loves hormone therapy understands hormone therapy understands why the studies were misinterpreted and he happened to be in charge of the gynecology association the day the announcement came out and when all of the newspapers went to him because they said what is the

gynecology association say he stood up and he said this is good for women period end of sentence

now they can talk to their doctors about what they really need and these labels like we're never

labels stopped decades of research they stopped decades of doctors wanting to do this because

how can you prescribe something something something that is safe but the box from the FDA says stroke blood clots heart attacks dementia how can you get away with prescribing it we did because we knew the data so well we thought but the regular clinicians are not gonna do that these box labels just got removed on my mom's birthday February 12th 2026 right may she rest in peace those box labeling gets removed just this past February now the real work begins now we get to teach people

how to do this now we get to teach the clinicians now we convince the rheumatologist and the

“neurologist and the orthopedic surgeons why this is essential for them to give good care for women”

and so we're gonna teach them what we've known for 30 years and women are going to do better let's talk about testosterone love it okay so who is it for what is it help and what are the biggest misconceptions Dr. Ruben that you hear okay so we have four major buckets when we're talking about hormone therapy okay whole body estrogen what's that estrogen patch estrogen pill estrogen pellet or estrogen gels any type of higher dose estrogen that's there to prevent osteoporosis help

with hot flashes night sweats 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 okay then there is if you have a uterus you or you want to 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 in the air especially if you have a uterus so there's whole body estrogen whole body progesterone whole body testosterone which we're going to 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 you can have some of the toolbox you don't need to have all the toolbox you said there are four types you've got full body estrogen

full body progesterone you've got vaginal estrogen and full body testosterone so let's talk about testosterone who's it for okay 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 they're ovaries make testosterone and their adrenal glands make testosterone for men their testicles make testosterone for women as they get into their thirties they're your testosterone starts to naturally drop for men there's also an age related decline but it is

not as sharp or as a 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 thirties testosterone might my thesis statement on testosterone it's not that serious people we want it to be serious if feel serious there's a motion 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 kind of down he falls asleep at dinner his erections aren't as strong as libido's getting a little low and his testosterone is below 300 and he has symptoms I'm going to give him testosterone and he's going

to feel amazing okay the testosterone deficiency can happen at any point so if you have any symptoms

of testosterone deficiency like I just described you shouldn't get a blood test at any age at any age so symptoms are low libido low energy erectile dysfunction osteopenia you know so sexual symptoms energy symptoms mood symptoms so we notice testosterone helps men's moods and so again men's testosterone there are guidelines it's there's about 27 different products there's

for women we have no FDA approved testosterone product for women none zero really it's approved

“in Australia New Zealand South Africa and England wait why there was a study that happened a”

billion dollars went into it they studied testosterone and the FDA came back and said okay there's

five years of data shows that it works for libido it shows that it's safe there was no major you know scary things that happen let's go back and talk about it and the FDA came back and said you know we didn't have breast tissue it was around the time that women's health initiative study came out soon 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 works in pharma but they were not going to do another

billion dollar study and no one was going to 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 we actually have a paper called the global

“consensus on testosterone therapy and 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 since we've talked about vaginal estrogen and we've talked about testosterone I'm now leaning in going well if I just want to reduce it down to one thing if I was going to 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

is DHA an option I'm so glad you asked because here's where dose matters okay so vaginal DHA is again micro dosing into the vagina to help with the local microbiome prevent UTI's 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 role for instead of vaginal estrogen just using vaginal DHA so you don't have to do both you could just use vaginal DHA the one reason why we talk about estrogen so much is it's less expensive so often patients can't get the vaginal DHA hey if you're listening world we would love vaginal DHA to be over the counter we would love for it to be affordable or covered by insurance because again this is life saving therapies that should not cost hundreds of

dollars for our patients so should you think about the DHA as like vaginal estrogen plus the 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 no question and you understand it so perfectly 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 DHA would be my first choice because it adds the androgen on onto it which the tissue needs both estrogen and testosterone so we like DHA I love DHA but I don't have access to it for all my patients and we're we're we have such a broad audience

“here that that's why you I don't sort of start with that because why why dangle something in”

front of you that you can't access okay so how do I know my testosterone is low 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 work as 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 libido is 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 one tenth the dose and what happens 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

without a device oh my gosh Dr. Rubin I watched TV and my body just felt the team glies again

they say you actually the data shows and people report their stress and continents gets a little better again major stress and continents there are things to do but the urethra the tube that your petrists surrounded by testosterone receptors also so if it 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 Belle at your exercise Ryan the gains that you make I'm trying to you you notice them a little bit more you get a little more credit right because 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 improvements what do you all say in your patients so they're then the libido 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 we definitely see improvements in libido and I would say it's it's the funniest part of it is the thing I see the most is that the words I feel like me and that's the magic words right when so estrogen and progesterone you feel better yes like a lot better like magically better I often start with estrogen and progesterone for many people because the hot flashes are so bad the sleep is so bad so if you can get that they feel

so much better but the testosterone when we add it is I'm back to me I have a patient that I

“had recently I just love this so much and she said to me because remember testosterone drops in your”

30s it's not yes testosterone drops in your 30s it's not about menopause it's actually age related so in your 30s if you have low libido pain with sex changes in your arousal orgasm in your 30s there is likely a biological basis and it is likely has something to do with testosterone so so this woman comes to see me she's in her 60s menopause consult you know typical menopause consult and we're giving her a whole body estrogen whole body progesterone testosterone vaginal hormones

and she comes to see me and she says Dr. Rubin I used to be able to orgasm three magical times

and they went away and they went away in my 30s and I always thought it was from my headache medicine

I was on amateur to lean at the time and I lost my ability to have three magical orgasms well Dr. Rubin six months into testosterone I mean my early 60s they are back and it was just she had never even thought that she could ask for them to come back and it was so beautiful because that's not what brought her into see me and yet it was the unintended magical consequences of this therapy that is not FDA approved for women global consensus that it works and not that

“serious there's no major risks there's no major side effects actually I believe very strongly”

that when you give women information about how their bodies work they make just excellent health care decisions for themselves I'm not here to tell you what to take what to do I'm here to share the menu with you I'm here to share the toolbox with you and to let you decide what you

want to put into your body I have a patient who's actually lives in my neighborhood and I never

seeing the neighborhood because she's always at work and she's busy but one day she's walking her dog and she sees me walking home from dropping a kids off at school and she runs up to me and I only know her from the sort of the exam room and everything and she runs up to me she says Dr. Rubin I'm sorry to bother you on your walk she said I just had to tell you my testosterone finally kicked in I said oh that's so great how long did it take she said it took five months Dr. Rubin

but it finally kicked in and I have to tell you something she said I finally feel back to me and guess what I just quit my job because I'm starting my own thing and she was so excited to just

“quit her job start her own consulting business and kick all of the ass and that's what I see”

everyday in my clinic is when you take someone who has castrate levels of hormones or fluctuating levels of hormones and they choose to use different things to help with their quality of life and their sexual health their health their hormonal health whatever it is they they get this energy they get this strength this inner strength it ends up helping their relationships it helps their work it helps their at home with their children it allows them to sleep it allows them to make decisions

not insurvival and I think that's the beautiful thing is they are a watch them go from I'm just here because it hurts I'm here because I get you TI's I'm here because I'm insurvival and then I get to sit there with popcorn and watch them get to thriving and making great decisions for themselves and I want that for everyone I can't be everyone's doctor I've tried it doesn't work like I can't

it's evidence based it's FDA approved maybe not for women but it's actually FDA approved it works there's decades of research why can't we have that for everyone so I love that story because it just shows that it's so much more than libido and it's about strength and hope and like an

“agency right like that's what we're doing here so how do you prescribe testosterone okay so again”

not that serious it feels scary because okay again politics again in the 1990s there was a big doping scandal where all these bodybuilders got testosterone and trouble and these bodies I'd have to do with women's health has a lot to do with women's health because these bodybuilders got us in trouble and everyone was afraid that everyone was amusing testosterone so the FDA and the DEA the drug enforcement agency put a big old label on testosterone that made it a controlled substance so when

you prescribe testosterone you need a DEA license like you are prescribing opioids so that provides challenges for people writing the prescriptions which is why we're advocating to the FDA to change that maybe by the time this airs they'll have made an announcement that they've changed it but anyway we use generic testosterone there's lots of ways to give testosterone but this is the most inexpensive way that we have found this costs about $8 per month because a tube of this generic testosterone my

male patients would use the whole tube every day they'd squeeze the whole tube out rub it all over their chest when we tell women to do it you use bigger than a pea size sort of a glob of testosterone so it's a gel so I've been about double that and then I would put it on my leg every single day so I'm putting it on my leg right now I'm wearing clitoris socks I don't know if everyone can see but my socks are clitoris on them but you just rub it on your on your leg you wash your hands

and you go on with your day so for me I pee first thing in the morning I have my S my testosterone

“on a shelf right where I pee my ankles exposed I put a blob it's 0.5 ml so if you want to be super”

precise you can take a syringe and fill it up with the testosterone and it's half a milliliter so just you can push it up a milliliter just it's a little bigger than a piece kind of a blob like a lime a bean I would say it's it's it's it's not it's so precise that's why we need a product and we need actual testosterone for women but it's not that serious people because it's not risky we give transgender patients 10 times the dose of testosterone and their their health

outcomes are fine so this is one tenth of the dose this is we don't give 10 times the amount of aspirin to people it takes four months for most people it's wild so there's really we don't see many side effects I would say think corny teenagers so sometimes oily skin acne hair growth hair loss but even then that's much higher doses for most people this is where we get nervous about things like pellets I'm not against pellets for anybody doesn't know pellets are these very

expensive almost look like tick-tax that are placed underneath your butt cheeks basically and they

give you long acting hormones over a few months and they often cost a lot of money and they are not regulated by the FDA and if the dose is too high you can't take them out so that's when you can see side effects so we typically recommend this more generic easier way to do it so that you don't get the side effects I'd love to have you talk a little bit about what you wish we knew that medicine has ignored there was a full page article in the New York Times science section and full page science

in 2022 was about how I give women a mirror and I show them their own genitals and I talk about their body parts I say this is your labium adjora this is your labium adjora this is your clitoris the title of the article was half the world has a clitoris why don't doctor study it and the brilliant author Rachel Gross who is so magnificently brilliant and she wrote a book called vagina Obscura and every chapter goes into why we don't know anything about the uterus why

we don't know anything about the clitoris why don't we know anything about the ovaries and and she says a beautiful beautiful job she's truly brilliant and she wrote this article in 2022 and like most things in our world the New York Times is like we don't want to publish this nobody's interested in this this isn't interesting to our readers and it was the most shared article in 2022 it went viral that doesn't surprise me and I'll tell you why I've had three children yeah

I am 57 years old I have never once in my life had a medical doctor a gynecologist

a nurse practitioner or any health care professional ever hold up a mirror and show me

“the that part of my body ever and and that's why I win 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

hood this is your vulva well of our vestibule this is your pelvic floor and we can go through all of

those details in 2017 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 what is that okay so I was 23% is one out of every four women one out of every four women as a clitoral adjora so I was where sleeps for this purpose so for everybody not here I have my sleeve over my fist okay she's pulled her there her sweater over her arm so her arm you can't

see my hand yes is hiding in there okay so every clitoris has a prep use 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 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 all of the same tissues they look the same under the microscope they're the same so 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 really so that's what a

literal adhesion is it means the hood of it is it's stuck and okay so here's so in 2017

we were the first to publish what we were the first 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 23% of the time yeah this was

“published in 2017 and that was all of the world's literature on this problem if you have”

literal adhesion yeah doesn't impact your ability to orgasm like what so yeah 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 literal problem what kind of doctor do you

go see there is no doctor trained in the clitoris there is a part of your body they don't train you in this no no one in fact when you are a medical student learning to do 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 27 to our doctor ruin I'm looking people 2017 all we knew is that people”

have these adhesions then I had three brilliant oh my god Mel these these students are gonna change the world three brilliant medical students who came to me and said Ruben we got to know more so they wrote up the IRB they looked at all the data and we had we do a very simple procedure in the office and you can go to the video journal of sexual medicine to watch us do this procedure it's published and we do this procedure where it's kind it's it's not that serious Mel it's kind of like

have you ever woken up and you've had eye crusties so so the point where your eye is shut okay that's an emergency you're blind you can't see you've got eye grip but you're like I'm not I don't need to go to the emergency room I can just pick off these crusties and open my eye it's essentially what we're doing here we stretch the tissue we open it up so that you can separate between the plane between the hood and the head so we do an office-based procedure mild numbing agent it's not surgery there's

no cutting there's no stitches or anything like that and so the medical students ask these patients and said well what happened what happened well some of these patients come with pain they have pain in their clippers they feel like there's a hair in their if you've heard an eyelash in your eye it's not cancer but you can't do anything unless that eyelash so we've people who every time they try to stimulate or touch their clippers and hurts it's irritated it's uncomfortable how many people are

walking around saying I don't like oral sex because they're schmutz under their clippers and it irritates the crap out of them a lot of women Mel a lot of women 23% in fact don't like like their clippers being touched because it's irritating and this by my god some have symptoms of decreased arousal decreased orgasm so we ask them all the data is remarkable 60 to 70% improvement in arousal orgasm satisfaction 70% decrease in pain if you had it and the kicker so these students are

presenting this research I mean it's my research but they actually looked at it I was drinking water

spit out water all over my computer because of the patients who had never had an orgasm in their

“lives dicks were able to orgasm with clearer stimulation after this procedure I couldn't even”

believe it myself and I'm the one doing the procedure since then some of my colleagues have replicated the data we've gotten the word out so more people are showing up with these issues this is not a rare problem we were just at the women's sexual health conference this year it was in Long Beach California and for the first ever time in history they did video abstracts where we presented video research and the very first video abstract was a case report that our team team did of a seven year old

that came to see us from Western Canada their parents found us from our research that we had done and this little girl since she had language said there is something sticking there's something stuck under my clitoris what she learned the word for clitoris she would point to it she would talk about it and it was so distressing that the parents did were beside themselves everything was a fight she was so

“she went to doctors and Canada and they tried to help but they didn't know what they were looking at”

and they offered her cognitive behavioral therapy and the nose the seven year old they were

said you need cognitive behavioral therapy the parents never gave up they believe this child thank God

for these parents they're just the most amazing people they brought her to my clinic I heard the story and I gave her this mirror I actually gave her this mirror and I showed her these models and I'm talking to the parents and and the child and we're talking about it and it with the mirror and I we then examined her and she saw everything we were doing and we saw that she had a completely clip like it was completely closed and I said is this where your pain is and she said yes and she saw it

and she saw what was happening and she saw my models of normal lies and she saw pictures of normal and she saw that and you saw this seven year old girl feel believed for the first time truly in her life by a doctor right there in that moment and so we ended up bringing her to the operating room because I didn't want to do a procedure of her awake and she woke up and her pain was gone it was gone completely gone she stopped complaining she stopped pulling she stopped agonizing it was it was gone

but we have a huge problem here because the doctors in Canada didn't know how to do this the doctors in America don't know how to do this and these parents can't keep coming it may have read here right this is like iCresties the iCresties might come back they can't afford to come to Washington DC every time this happens this is not a rare problem this is 23% of people on an organ that no one has ever bothered to study wow what was the result of diagnosing the literal adhesion and then doing a simple

office procedure that changed it so in this study and this was again only 41 patients in this study since there have been a published reports of even more patients than this we had 76% improvement in

sexual arousal 64% in the improvement ability to orgasm 38% of the patients who had never had an orgasm

we're able to orgasm after this procedure 83% were very satisfied with the procedure and this isn't major surgery right this isn't like body mutilation this is literally like opening your eye after having iCresties but it's more importantly most none of us know nobody knows one and four women have this and it's impacting your life or your ability to orgasm or experience pleasure or you're feeling discomfort yeah to know that the simple procedure and just being aware of this has such profound

positive impacts listen we need more data but the very first thing people can do is get a mirror at home and look at your own body why don't you show us what we're supposed to say so all right this is

“really important mel because you don't go to a doctor for face pain okay the reason you don't”

go to a doctor for face pain is because you have a lot of parts on your face and there's a lot of different doctors that you go to for your face so you don't show up at the dentist because you have eye pain you don't show up at the dermatologist because you have a lip problem or a teeth problem or a throat I mean like people don't even have the language for their genitals they say down there they use in uendo they have some stupid name for it or God forbid they call it a vagina where

the parts that you can see are the vulva not even the vagina and vulva is a stupid name too because there's no vulva for men like so the more you know your own body parts the more you as a patient can show up and say there is a problem with my clitoral hood there is a problem with my vulva vestibule what is my vulva vestibule you don't even know what it is how are you going to show up to the doctor when that is the most common reason people have pain with sex wait the most common reason people

have pain with sex is vulva vestibule what exactly mel let's talk anatomy my favorite topic in the

and the pelvis is basically surrounded by big giant muscles which we call the pelvic floor it's

“basically a bowl the pelvis is a bowl and the lining of the bowl is filled with thick big giant”

muscles okay and I don't know about Boston I trained in Boston I went to college in Boston to medical school in Boston but man in DC we have a lot of tight asses and what happens is these pelvic floor muscles get really can get really tight just like your neck muscles can get tight or your back muscles can get tight and when you have tight muscles in your pelvis it can cause constipation it can cause urinary frequency urinary urgency and pain with sex because these muscles

surround the whole that you are trying to have a specular exam or a tampon or devices or a penis or whatever you want to put in there the rectum is where poop comes out of and if that is tight it's hard to get poop out and so it can hurt or it can cause constipation and we spend all day long using our pelvic floors and not exercising them not training them and if they have a problem or say a watermelon comes out of them like a child's head we don't even think about rehab if you got

a knee replacement you would go to physical therapy three times a week if you have three children come out of your vagina or out of your abdominal muscles if you have a c-section barely anyone

“gets told to go to rehab and retrain their muscles okay never but it's the most important thing”

in the world so pelvic floor physical therapists are highly trained professionals who are trained to rehabilitate and help these muscles if they're too tight if they're too weak if they are not working like any muscles in the body can have problems these muscles are no different does I make sense ma very much so okay so it's all muscle and then on top of the muscle is you're going to have the part that you can see so if you take a mirror so this is a model of very

silicone model of a vulva and you have a labia majora right so this is the labia majora it's just skin and under the outer lip the outer labia right and it's just skin but if you push on it the muscles are underneath then you have the labia menorah which a lot of people call lips I don't know I find it kind of ikki I call them wings wings just sounds like a thing that I was calling so I was calling it the wrong thing okay so labia majora is the pad that sort of outside of the labia

menorah and that flattened out in menopause by the way we don't really know why but it can get flattened then there's the labia menorah or those inner wings and those coming all shapes and sizes but they're hormonally sensitive they're hormonally sensitive babies have very small ones you grow them in puberty and they resorb and disappear in menopause they get smaller and menopause so remember when you play with hormones their consequences so likely birth control affects the size

of the labia likely things like spurnalactone likely breastfeeding all the changes with hormones can probably change the size of the labia so when women go get surgery to alter the size of their labia

they do I beg it's a billion dollar industry now where have we been labia plastics are one of the

most common procedures women will show up to get their labias operated on because they feel they're

“too floppy or they get in the way they can be uncomfortable for women and if you want to do”

your body you do whatever you want but there are nerves in there that are important for sexual health because we see a lot of patients who have they think they're abnormal when really big labia are hormonally healthy labia so we don't educate on what normal labia are if you follow those inner wings up you get to the hood of the clitoris okay so you follow the inner wings the inner labia up and you get to the hood of the clitoris if you pull back those wings you will see the very

tip at the tip of the head of the clitoris so right here you follow the labia up and you get to the tip which is like the tip of the iceberg so um penises right have a tip of the head of the penis that's not the only part that you touch during sex or an intimacy right there's this whole shaft thing and actually penises are there's the shaft and then they split into two and they go into legs that go all the way to a man's butt bones well guess what the clitoris is the thing it's

what's in the two it goes from to two it goes all the way down to your butt bones so if you go back and forth on your butt bones and you feel your sits bones yeah that's where your clitoris inserts shut up which means there's a reason why vibrators feel so good anywhere along the lines of the labia majora because that's where your clitoris lives so the tip of the iceberg but the legs

are underneath the labia majora and down the whole length of the wings whoa so it basically

sits like that wow and so this is why but it's all underneath the surface my friends if a penis

well the vibrator companies would be gaugillian airs not just billion airs but the point is is your clitoris that which is a penis it's the same thing how do you fully activate it

“well you have to activate it from underneath the surface and you've had wonderful guests on that”

have talked about pleasure and things like that but the truth is is that this is not the inside

canal the vagina which is where penetration happens yes and that's why so few women orgasm with penetration it's not because they're broken it's because that's not how orgasm works so the more our patients can understand how orgasm works understand their own anatomy understand what feels good for them we don't I have never had a man come to see me Mal I see a lot of men never had a man come to see me it's Dr. Rubin I'm broken I can't have an orgasm

I'm just rubbing my inner thigh over and over again and no matter how hard I rub my inner thigh I can't orgasm why have I never had that console because every man knows he has to stimulate his penis to orgasm yet I have women come to see me and say I mean penetration and is not doing anything for me well a little up a little outside right like you might need vibration

“like this is normal and so education is so important here because we educate boys and men”

how penis works and there's no doctor who examines the clitoris Dr. Rubin what is the vulva vestibules is it the wings is that what that is no okay so you go to the clitoris you pull back see if you have adhesions well now we keep opening those wings okay there is a rim of tissue that surrounds the inside lining of the labia so if you spread like a book those labia you spread it open it's everything you can see at the surface so that your rethras the tube

you pee through and the tissue above it around it and below the opening of the hole that the

vagina is in is called the vulva vestibule this tissue is the most important part of the body

that you've never heard of before why is it important because the labia is skin it's tough like skin right the vulva vestibule is delicate and thin and it is actually made up of bladder tissue and so just like your mouth or your outside of your cheek and the inside of your cheek are different the skin of the labia is very tough and safe that vulva vestibule is thin fragile hormonally sensitive and it's the bladder tissue so if that's dry and irritated it doesn't have hormones and scrapes

again something over and over again in a high contact sport like sex you can have urinary symptoms frequency urgency leakage pain with sex feelings of a UTI but not actually have an infection

so we do what's called a q-tip test one of the most important test what you can do this at home

you take a q-tip you can touch the labia and you see you won't have pain then you can spread the labia and touch this area of the vulva vestibule and you'll say oh that feels like a UTI oh that feels like it's not supposed to hurt it should have no pain and yet so many women have pain there because of their birth control pills or menopause or their breast cancer treatment or things like that because the hormonal changes that happen in this tissue is impacting

the health of that tissue causing pain yeah and so vaginal hormones help with this tissue you say Dr. Ruben that sex shouldn't hurt where the most common causes of pain with penetration that you're seeing 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 acne medications breast feeding endocrine therapy for breast cancer

perimenopause and menopause that is so common to have pain with sex and so treatable with vaginal hormones which we talked about it like 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 muscles think squeeze your eyes close 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 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 and no metriosis causing muscle problems or you can 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 and there are surgeries that sometimes we have to do for this problem the most important message I

like you don't show up with face pain you want to know is it like where is the problem is it

the teeth and just like there is a specialist all over your face there are specialists at much fewer for this part of the genitals because we haven't valued or cared about this part of body for women so that 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's there's you know

um 1700 within our women's sexual health specialty not everyone is 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”

going to give you a diagnosis because that matters then for treatment and that's where the mirror

comes in handy because when you can see what's going on again you never heard of a vulva of our

vestibule in front of me in her life 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's diagnosable and they're they can see it with their eyeballs life changing life changing I would love

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 ten minute appointment with their you know gynecologist or the primary care doctor what exactly should they say to be taken seriously

“I think it's really important for patients to educate themselves 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? I love the way you just framed that I knew the right person to help me with these issues because so many of your clinicians

I know a lot about the things I know a lot about there if you ask me about diabetes right now I would look crazy and I don't know any of my 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 you 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 want to 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're the center of the team they're 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 to your clinician because they don't want to spend 10 minutes with you either they also would like to spend more time with you 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 if you're a health care 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 going to send to their sister or brother who's a nurse they're going to send to their partner who may be a doctor they're going to send to their friend who's the gynecologist of the friend group and say oh my gosh like you got to hear this where what is the best place for a medical professional or somebody working in health care to go to become more educated about what you've just shared you can learn new things

for clinician can learn new things whether it's taking my course online while you drive to work the menopause society has great content is wish 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 Kasperson has an amazing podcast and is a dear friend of mine uh is wish 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 orthopedic surgeon you can learn how to do this

if I can do this as a neurologist you certainly can do this and here I will help mentor you um that's really what it's going to take but i'm hopeful for there's more money in this than ever before there's more industries in this than ever before doctor roven 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 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 so doctor roven for somebody who's been hanging on every word and now you've opened the door we want to walk through and just jump in and learn even more where do we go 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 because you can learn the new things that i'm learning while it's happening that's doctor roven on social media our website is a

wonderful place for education so Rachel roben md.com you can find our courses our updates our new letters very popular 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've 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 proof 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 in the movie got made because of that i'm in it i'm not the main star of it and it is fabulous this second thing that's a much watch is the balance documentary series again balance balance it's called balance it is all about

paramount plus it is these lady monks who are also documentary filmmaker that we're going through paramount was 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 paramount pause and hormones so they interview all of the experts they go on their own journey it's a four-part series on apple tv

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 women your all edges 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 Perry menopause i'm in it i'm not the star this is like the best i would say i've sidekick energy like i love being in things but not like the main event which is why this makes me very uncomfortable now um but these three documentaries are just showing how much excitement there is about this topic how much that people want to 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 i absolutely love that and what i would 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 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've shared with us today this is been absolutely extraordinary doctor ribbon what are your parting words you matter your life matter 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 because you deserve all of that well doctor Rachel Ruben you are a gift to all of us on behalf of every single woman

that will listen to this i just want to 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

and i also want to 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 going to 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 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 doctor Ruben 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 learn today is going to help you do that all right i'll see you in the very next episode i'll welcome you in the moment you hit life much honey got okay so let's do this i'm warming up i'm sure i know i know i'm sorry apologies okay i'm not so no no said thank you thank you you're welcome i'm warming up left me oh sorry guys let's you and thank you for doing this with me i know i'm very

long-winded you're unbelievable every time one of my daughters calls about a UTI and i have a UTI again and i have it oh you're an acting medication oh like you know have we done a PhD thing

“i know you want to talk about HRT today but i think my mind has changed that we should only talk”

about heated rivalry therapy today well if you just watch heated rivalry you don't need testosterone because it's gonna turn you on so much thank you thank you so much for having me of course it won't be the last time i'm sure oh and one more thing i know this is not a blooper this is the legal language you know what the lawyers write and what i need to read to you this podcast is presented solely for educational and entertainment purposes i'm just your friend i am

not a licensed therapist and this podcast is not intended as a substitute for the advice of a physician professional coach psychotherapist or other qualified professional got it good i'll see in the next episode series xm podcasts