Dr Rachel Rubin: The Truth About HRT & Menopause Doctors Won't Tell Women | Dr Rachel Rubin
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Quick Read
Summary
Takeaways
- ❖Over 75% of women who could benefit from generic vaginal hormones are not receiving prescriptions, despite their ability to prevent UTIs and improve sexual quality of life.
- ❖The word 'clitoris' is not on the checklist for OB/GYN training in 2026, highlighting a severe gap in medical education regarding female sexual anatomy and function.
- ❖Testosterone levels in women begin to drop precipitously in their 30s, affecting libido, orgasm, and arousal, yet this is often overlooked in medical discussions about hormones.
- ❖Birth control pills can lower testosterone, leading to decreased libido and pain with sex in a subset of women, as ovaries are suppressed from producing their own hormones.
- ❖GLP-1 weight-loss drugs (e.g., Ozempic, Mounjaro) are showing sexual side effects in women (both positive and negative), but there's a lack of published research on this aspect.
- ❖Vaginal hormones (estrogen or DHEA) are safe at any age, even for those with cancer or blood clots, and can prevent UTIs by over 50%, alleviate dryness, and improve sexual function.
- ❖The Women's Health Initiative (WHI) study from the early 2000s was widely misinterpreted, leading to a fear of hormone therapy that has deprived a generation of women of beneficial treatment.
- ❖Up to 75% of women experience painful sex at some point, often due to hormonal changes, skin conditions, muscle tightness (pelvic floor), or nerve issues, requiring specialized diagnosis.
- ❖The 'orgasm gap' between men and women is largely due to a lack of education, as most women orgasm from clitoral stimulation, not penetration, and many don't know where their clitoris is.
- ❖Clitoral adhesions, where the clitoral hood is stuck to the head, affect about 23% of women and can be easily resolved with a simple office procedure, improving orgasm and satisfaction by 60-70%.
Insights
1Systemic Failure in Women's Hormonal and Sexual Healthcare
The medical system profoundly fails women in hormonal and sexual health. Dr. Rubin highlights that even highly affluent women like Melinda Gates, Oprah, and Halle Berry have struggled to receive proper care, often seeing multiple doctors before getting accurate diagnoses or appropriate hormone therapy. This failure stems from a critical lack of education in medical schools and residencies, where topics like the clitoris, menopause, and sexual pain are not adequately covered. Doctors often have strong opinions without data, or dismiss women's symptoms due to time constraints or lack of knowledge.
Melinda Gates saw three doctors for hormone therapy; Oprah saw five for perimenopausal heart palpitations; Halle Berry was misdiagnosed with herpes instead of genitourinary syndrome of menopause. The word 'clitoris' is not in OB/GYN training checklists. (, )
2Misconceptions and Decline of Testosterone in Women
Testosterone is not solely a male hormone; women produce it, and it's crucial for libido, arousal, orgasm, and body image. Unlike estrogen, which drops at menopause, female testosterone levels begin a significant decline in the 30s. This early drop can lead to symptoms like decreased libido, longer orgasm times, and reduced engorgement of the clitoris, often years before menopause is typically considered.
Testosterone is a hormone, not gender-specific. Graphs show testosterone precipitously drops in women's 30s, leading to reduced libido, arousal, and orgasm. (, )
3Impact of Birth Control and GLP-1s on Female Sexual Health
Combined birth control pills work by tricking the body into not ovulating, which shuts down the ovaries' natural production of estrogen, progesterone, and testosterone. While they replace estrogen and progestin, they do not replace testosterone, leading to lowered libido and pain with sex in a significant subset of users (up to 27%). Similarly, new GLP-1 weight-loss drugs (Ozempic, Mounjaro) are showing sexual side effects in women, with about 25% reporting changes, yet there is a severe lack of published research on these effects.
Birth control pills lower testosterone by shutting down ovarian hormone production, causing low libido. Studies show up to 27% of birth control users report decreased libido. A survey of 1,000 women on GLP-1s found 25% reported sexual side effects. (, , )
4Vaginal Hormones: A Safe, Underutilized Solution for Genitourinary Health
Vaginal hormones (microdoses of estrogen or DHEA) are a 'magical solution' for common genitourinary issues. They support the bladder and vagina by maintaining an acidic microbiome, preventing UTIs by more than half, and alleviating pain with sex, dryness, urinary frequency, urgency, and leakage. These hormones are safe for women of all ages, including breastfeeding mothers and those with complex medical histories like cancer or blood clots, yet are drastically underprescribed.
Vaginal hormones are safe for grandmothers and breastfeeding mothers. They prevent UTIs by over 50% and help with pain, dryness, and urinary symptoms. Estradiol cream costs $14 and lasts 2.5 months. (, , )
5The Misinformation of the Women's Health Initiative (WHI) Study
A pivotal 2002 press conference misinterpreted the Women's Health Initiative (WHI) study, falsely claiming that hormone therapy caused cardiovascular disease and breast cancer. This led to a mass abandonment of HRT and a generation of doctors untrained in its prescription. Subsequent re-analysis by the original authors in 2025 clarified that for women under 70, the type of hormone therapy studied showed no increased risk of cardiovascular disease or stroke. This historical misinterpretation continues to impact current medical practice, with only 1.7% of eligible women receiving HRT prescriptions.
The WHI study was stopped early and misinterpreted, leading to widespread fear of HRT. The same authors later clarified that hormone therapy below age 70 has no increased cardiovascular or stroke risk. Only 1.7% of eligible women receive HRT prescriptions. (, )
6Addressing the Orgasm Gap and Clitoral Adhesions
The 'orgasm gap' (women orgasming less than men) is primarily an education problem. Most women orgasm through clitoral stimulation, not penetration, yet many do not know their clitoral anatomy. A common physical blocker is clitoral adhesion, where the clitoral hood is stuck to the glans, affecting about 23% of women. A simple in-office procedure to release these adhesions can improve orgasm, arousal, and satisfaction by 60-70%. Doctors rarely examine the clitoris or inquire about orgasm.
Women are not orgasming as much as men due to lack of education; most orgasm via the clitoris, not penetration. 23% of women have clitoral adhesions; removing them improves orgasm by 60-70%. (, )
Bottom Line
The word 'clitoris' is not included in the mandatory learning checklist for OB/GYN training in 2026, indicating a profound, ongoing systemic neglect of female sexual anatomy in medical education.
This omission means that the very specialists women consult for reproductive and gynecological health are not formally trained on the primary organ of female pleasure, leading to widespread ignorance among practitioners and inadequate care for patients experiencing sexual dysfunction.
There's a critical opportunity for medical curriculum reform and specialized training programs to integrate comprehensive sexual anatomy and health education for OB/GYNs and other relevant medical professionals. This could be driven by advocacy groups, medical societies, or even private educational initiatives.
Only 1.7% of women who should be offered hormone therapy prescriptions are actually receiving them, despite updated data clarifying its safety and benefits for those under 70.
This represents a massive failure in healthcare dissemination, leaving millions of women to suffer from preventable symptoms of menopause (hot flashes, bone loss, UTIs, sexual dysfunction) due to outdated fears and lack of doctor training. It underscores a significant gap between scientific evidence and clinical practice.
There's a substantial market opportunity for direct-to-consumer health platforms or specialized clinics that prioritize evidence-based hormone therapy, educate patients, and train practitioners. Advocacy campaigns are also needed to inform both patients and general practitioners about current HRT guidelines and benefits.
Vaginal estradiol cream, a generic and inexpensive medication (as low as $14 for 2.5 months' supply on Mark Cuban's pharmacy), is 'literally better than Viagra' for women, preventing UTIs, alleviating painful sex, and enhancing arousal and orgasm, and is safe at any age.
This highlights a severe market inefficiency and information asymmetry where a highly effective, affordable, and safe treatment for common, debilitating female health issues is not widely known or prescribed. Many women suffer needlessly due to lack of awareness among both patients and doctors.
Entrepreneurs could focus on increasing accessibility and awareness of generic vaginal hormones through telehealth, online pharmacies, and educational campaigns. This could involve partnerships with women's health advocates or direct-to-consumer marketing that emphasizes cost-effectiveness and broad safety.
Opportunities
Specialized Women's Sexual Health Clinics
Establish clinics focused solely on women's sexual and hormonal health, staffed by highly trained specialists (like Dr. Rubin) who understand the nuances of hormones, pelvic floor issues, and clitoral anatomy. These clinics would offer comprehensive diagnostics, evidence-based hormone therapy, and procedures like clitoral adhesion release.
Medical Training Programs for Women's Sexual Health
Develop and offer accredited continuing medical education (CME) courses and residency modules specifically on female sexual anatomy, hormonal health (beyond estrogen/progesterone), and the latest evidence-based treatments for conditions like GSM, low libido, and painful sex. This addresses the critical lack of training in current medical curricula.
Affordable Online Pharmacy for Women's Hormones
Create or expand an online pharmacy platform (similar to Mark Cuban's Cost Plus Drugs) specifically for generic, low-cost vaginal hormones (estradiol cream, DHEA) and other essential women's health medications, coupled with accessible teleconsultations to ensure proper prescription and usage.
Educational Platform for Couples on Sexual Health
Develop an interactive online platform or app that provides evidence-based education on sexual anatomy, physiology, common issues (e.g., orgasm gap, painful sex), and communication tools for couples. It could include modules on 'sexual financial literacy' and guided conversations to foster intimacy and address specific concerns.
Key Concepts
Financial Literacy for Sex
Dr. Rubin uses financial literacy as a framework for understanding sexual health. 'Checking and savings accounts' represent basic needs like education, nutrition, sleep, communication, and safety. '401k' signifies long-term investment in health, like hormones, pelvic floor therapy, and sex therapy. 'Crypto' represents risky, unproven quick fixes like cosmetic procedures or unverified supplements, which should not be the starting point for sexual health.
Lessons
- If experiencing painful sex, low libido, or recurrent UTIs, actively seek out specialized gynecologists or urologists with a known interest in pelvic pain and sexual health, and don't hesitate to get multiple opinions.
- Discuss with your doctor the possibility of using vaginal hormones (like estradiol cream or DHEA) for genitourinary symptoms (dryness, pain with sex, urinary issues), as they are safe, effective, and inexpensive at any age.
- Engage in open and curious communication with your partner about sexual preferences, pleasure, and any challenges. Consider using external resources like sex therapists or communication apps to facilitate these sensitive conversations outside the bedroom.
- Educate yourself and your partner about female sexual anatomy, particularly the clitoris, and understand that most women orgasm through clitoral stimulation, not solely penetration.
- If you are a woman experiencing difficulty with orgasm, ask a specialist to check for clitoral adhesions, a common and easily treatable physical blocker that can significantly improve sexual satisfaction.
- Recognize that 'spontaneous' sex is often a myth; scheduling intimate time can be a powerful way to prioritize connection and pleasure, especially in busy lives, without sacrificing eroticism.
The 'Financial Literacy for Sex' Framework for Great Sexual Health
**Establish 'Checking & Savings' (The Basics):** Prioritize fundamental well-being: good education about sex, balanced nutrition, regular exercise, sufficient sleep, and safe, open communication with your partner. Ensure a foundation of safety and trust in the relationship.
**Invest in '401k' (Long-Term Growth):** Seek professional support for optimized sexual health. This includes consulting doctors knowledgeable in hormone therapy, engaging in pelvic floor physical therapy for muscle health, considering sex therapy for mental and emotional aspects, and exploring sex toys or devices to enhance pleasure and exploration.
**Avoid 'Crypto' (Risky, Unproven Fixes):** Be wary of quick-fix solutions advertised on social media, such as injections, cosmetic procedures, or unverified supplements. These are often expensive, lack scientific backing, and should not be the primary approach to resolving sexual health issues.
Notable Moments
Dr. Rubin expresses 'rage' over the systemic failure to provide women with essential sexual and hormonal health information and care.
This sets the tone for the podcast, highlighting the severity and emotional impact of the medical disservice women face, driven by a lack of education and outdated practices.
The host shares his personal experience of his ex-partner not enjoying sex due to an undiagnosed physiological issue, leading to relationship breakdown and self-blame.
This personal anecdote powerfully illustrates the real-world consequences of poor sexual health education and communication, showing how biological issues, when unaddressed, can destroy relationships and cause immense personal hurt and misunderstanding.
Quotes
"The word clitoris today in 2026 does not exist in the checklist for what an OBGYN has to learn in their training."
"We don't tell men you can't have this. You can't do this. We talk about shared decision-making. We talk about risks. We talk about benefits. For some reason we don't do that enough in women's health."
"Testosterone is just a hormone. It's not a male hormone, a female, it's just a hormone. It's also not a menopausal hormone. We think of menopause as estrogen starts to drop, right? So menopause is a castration event."
"Hormone therapy causes cardiovascular disease and breast cancer. And overnight, a multi-billion dollar industry went to nothing. Everyone was told throw your hormones in the garbage. This is dangerous. What was crazy is those people who were prescribing hormone therapy were looking around saying, 'I don't understand. My patients aren't dying of heart disease. They're not getting extra breast cancers. Like, this doesn't make any sense.' And when people actually looked at the study, it didn't say any of those things. It was wild how misinterpreted this study was."
"If sex is painful, you need to figure out why it's You deserve a diagnosis. You deserve an answer. You deserve to understand exactly why sex is painful."
"Women are not orgasming as much as men. The data's very clear there. And I think the majority of problem is education. Women think that orgasm comes from penetration. But the clitoris is how most women orgasm."
"It was really the whole time not me against her or her against me. It was me and her against the problem."
Q&A
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