Dr Rachel Rubin: Women’s Sexual Health, Menopause, Hormone Replacement Therapy (HRT), and Orgasms!

Episode Summary

Executive Summary: The episode argues that women’s sexual and hormonal health is widely misunderstood, under-taught, and under-treated in medicine. Dr. Rachel Rubin explains how hormones, vaginal estrogen/DHEA, testosterone, pelvic floor health, and communication can dramatically improve libido, pain with sex, orgasms, UTIs, and overall quality of life, while calling out medical training gaps and the lasting harm of misinformation about HRT.

Main Topics: Medical system failure in women’s sexual health (Priority: 5/5): Dr. Rubin says women are routinely dismissed because clinicians are undertrained in sexual health, menopause, hormones, and pelvic pain. She argues the problem is systemic rather than individual negligence, with even wealthy women struggling to get correct diagnoses and treatment. Hormones across the female lifespan (Priority: 5/5): The discussion covers puberty, reproductive years, perimenopause, menopause, breastfeeding, and post-menopause, emphasizing that estrogen, progesterone, and testosterone all matter for symptoms, libido, sleep, mood, bone health, and urinary function. Vaginal estrogen and DHEA as foundational treatment (Priority: 5/5): Rubin strongly advocates for local vaginal hormones to treat dryness, painful sex, urinary urgency/frequency, leakage, and recurrent UTIs. She frames them as safe, low-cost, and underused therapies that can be preventive, not just reactive. Testosterone and libido/arousal (Priority: 4/5): She explains that testosterone is not just a ‘male hormone’ and that women’s testosterone drops in their 30s, often affecting desire, arousal, orgasm, and satisfaction. She argues many women could benefit from properly dosed testosterone therapy. Pain during sex and pelvic floor dysfunction (Priority: 4/5): Rubin outlines that painful sex can stem from hormonal tissue changes, pelvic floor muscle issues, skin disease, nerve problems, spine issues, or endometriosis. She urges proper evaluation rather than normalizing pain. Orgasm gap, clitoris education, and sexual communication (Priority: 5/5): She says many women are taught penetration is the path to orgasm, when the clitoris is the primary source of pleasure for most. She stresses anatomy education, partner curiosity, and honest communication as core to closing the orgasm gap. Porn, fantasy, scheduling, and modern relationship dynamics (Priority: 3/5): The conversation explores how pornography can shape expectations, how couples can use scheduled intimacy or sex therapy to improve connection, and how curiosity, consent, and after-action communication can support better sex and relationships.

Key Arguments: Women are not getting good sexual health care because medical education largely omits clitoral anatomy, libido, menopause care, and vaginal hormone therapy. Hormone therapy is often feared because of misread early-2000s research, but the real data and modern guidance support informed, individualized use for many women. Vaginal estrogen/DHEA is one of the most effective and safest interventions for urinary symptoms, recurrent UTIs, dryness, and painful sex. Testosterone matters for women too, especially for libido, arousal, orgasm, and satisfaction, and it often declines before menopause. Painful sex is not normal and should prompt evaluation for hormonal, muscular, dermatologic, neurologic, or structural causes. Most women do not orgasm primarily from penetration; better education about clitoral anatomy and stimulation is essential. Communication and curiosity between partners are as important as biology; many relationship problems are actually misunderstandings about symptoms or preferences. Modern burnout, stress, sleep loss, and over-scheduling can suppress desire, making planned intimacy and intentional connection useful tools. The orgasm gap reflects both anatomy and education, not just psychology or relationship quality. Women need access to a full toolbox of treatments, not blanket denial or one-size-fits-all medical advice.

Data Points: Women prescribed hormone therapy: 1.7% - Rubin says only a tiny share of women who should be offered hormone therapy actually receive prescriptions. Large database collections not getting prescriptions: >75% - She says most women in large datasets are not getting prescriptions for vaginal hormones or related treatments. Medicare patients getting prescriptions: <9% - Rubin cites low prescribing rates among Medicare patients for relevant hormone therapies. Birth control-related libido decrease: Up to 27% - She cites studies reporting decreased libido in some people using birth control. Women reporting sexual side effects from GLP-1s: About 25% - Based on an unpublished survey of 1,000 women who used weight-loss drugs. Of those with GLP-1 sexual side effects: About 50% lower function; about 25% better - Among respondents reporting sexual side effects, about half said function worsened and a quarter said it improved. Painful sex prevalence: Up to 75% at some point in life - Rubin says many women experience painful intercourse at least once in their lives. Persistent chronic pain during sex: 10% to 20% of U.S. women - She cites prevalence estimates for ongoing dyspareunia. Menopause age range: 45 to 55; average 52 - Rubin describes the typical age range for menopause and the average age of onset. Perimenopause window: About 35 to 45 - She says hormone changes can begin roughly 10 years before menopause. Female testosterone decline: Starts in the 30s - She notes testosterone drops earlier than many people realize, often affecting libido and arousal. Clitoral adhesions prevalence: About 23% - Rubin says a significant minority have a clitoral hood adhesion that can impede stimulation. Improvement after adhesion removal: Up to 60% to 70% - She reports improved orgasm, arousal, and satisfaction after office-based treatment. Vaginal hormones preventing UTIs: More than half - She says research since the 1990s shows local vaginal hormones reduce UTI risk by over 50%. Combined-pill effect on ovaries: Fake estrogen/progestin suppress ovulation - Explains how birth control pills prevent ovulation by signaling that hormones are already present. Female orgasm during penetration average: Usually well over 13 to 15 minutes - She contrasts women’s average orgasm timing during penetration with men’s average timing. Male penetration orgasm average: About 5.5 minutes - Used to highlight the orgasm gap and differences in sexual response patterns. Men viewed porn regularly (18-35): 75% to 90% - Referenced to show male-heavy consumption patterns. Women viewed porn regularly (18-35): About 34% - Referenced to show a large gender gap in pornography use. Spontaneous arousal in men: About 70% - Discussed as the more common arousal pattern in men. Spontaneous arousal in women: About 10% to 15% - Discussed as less common than in men. Responsive arousal in women: About 40% to 50% - Used to explain why many women respond after stimulation begins. Mixed arousal style in women: About 35% - Cited as another common pattern among women.

Pivotal Quotes: "I am filled with rage because I do think that people are limiting their ability to have great sex, great relationships, and great health because they aren't having access to all the information that they could." — Dr. Rachel Rubin: Explaining why she is so passionate about sexual and hormonal health advocacy. "The clitoris is how most women orgasm, and yet most women do not know where their clitoris is." — Dr. Rachel Rubin: Used to illustrate the education gap driving the orgasm gap. "If you do that twice a week, it can prevent death from urinary tract infections." — Dr. Rachel Rubin: Describing vaginal estrogen use and its preventive health benefits.

Implications: The episode pushes listeners to treat sexual health as real medicine: learn anatomy, demand better evaluation, ask about hormones, and communicate openly. For healthcare, it argues for major changes in training, prescribing, and patient education.