The Most Important Conversation You’ll Ever Hear About Women’s Health | Dr. Rachel Rubin

Hormone changes, not just menopause, are a primary cause of genitourinary symptoms. Conditions like birth control use, breastfeeding, and breast cancer therapies, alongside perimenopause and menopause, lead to a drop in estrogen and testosterone. This hormonal shift alters the vaginal and bladder microbiome, increasing the risk of UTIs, dryness, irritation, urinary frequency, urgency, and pain with sex. This condition, termed Genitourinary Syndrome of Menopause (GSM), is misnamed as it affects women throughout their lifespan.

People on birth control pills, breastfeeding, or on hormone therapies for breast cancer, perimenopause, and menopause can drastically increase their risk of UTIs. Vaginal hormones prevent urinary tract infections by more than half. The vagina needs hormones like a plant needs water. When perimenopause happens or other things like breastfeeding or birth control pills, the tissue can start changing the way that it looks and feels. The pH starts to rise, bad bacteria grow, and good bacteria shrink.

Microdosed vaginal hormones (estrogen or DHEA) are highly effective in preventing UTIs and alleviating GSM symptoms. They work locally to restore the vaginal and bladder microbiome and tissue health. Historically, these products carried false, blanket warning labels from the FDA, linking them to risks like stroke and cancer, based on misinterpretations of a 2002 study (Women's Health Initiative). These labels were officially removed in February 2026 after extensive advocacy, clarifying that vaginal hormones are safe, even for individuals with cancer history, and do not cause systemic side effects.

Using vaginal hormones prevent urinary tract infections by more than half. We've known about this since the 1990s. We've had products since the 1970s. The FDA removed the box labeling on vaginal hormone products in February 2026. These medicines were always safe, life-saving, and the label was wrong. There is no data to show harm in these products. A paper looked at 50,000 women with active breast cancer, and those who took vaginal estrogen died less.

Testosterone is a crucial human hormone, not exclusive to men, and women's levels naturally decline starting in their 30s. This decline impacts libido, energy, mood, and even urinary continence. Despite global medical consensus on its safety and efficacy for women, particularly for low libido, there is no FDA-approved testosterone product specifically for women in the United States. This forces clinicians to use lower doses of male testosterone products 'off-label,' highlighting a significant gap in women's healthcare.

Around 35, your testosterone starts to drop precipitously. Low libido, increase in UTIs, increase in pain with sex. For women, we have no FDA-approved testosterone product for women. None. Zero. It's approved in Australia, New Zealand, South Africa, and England. We have a paper called the global consensus on testosterone therapy in women. It says global consensus that testosterone therapy is safe for women and works.

Approximately 23% of women have clitoral adhesions, where the clitoral hood is stuck to the glans, preventing full retraction. This condition is often undiagnosed because medical professionals are not routinely trained to examine the clitoris. Adhesions can cause pain, irritation, and significantly decrease arousal and orgasm ability. A simple, in-office procedure to release these adhesions has shown remarkable improvements (60-70% in arousal/orgasm, 70% decrease in pain), even enabling orgasm for some who never had one before.

23% of all women who come into the clinic have what's called clitoral adhesions. No doctor is taught how to examine the clitoris or ever routinely examines the clitoris. In 2017, we were the first to publish that it is either mild, moderate, or very severe. We do an office-based procedure, mild numbing agent, no cutting, no sutures. 60 to 70% improvement in arousal, orgasm, satisfaction, 70% decrease in pain. Of the patients who had never had an orgasm in their lives, six were able to orgasm with clitoral stimulation after this procedure.

The current medical system is not designed to adequately address women's sexual and hormonal health. Doctors, including gynecologists, receive minimal to no training on topics like the clitoris, female sexual function, or modern hormone therapy. This lack of education, combined with short appointment times and historical misinformation (like the WHI study's impact on HRT), leads to women being dismissed, misdiagnosed, or told their symptoms are 'all in their head.' This systemic issue results in widespread suffering from treatable conditions.

The word clitoris doesn't appear in what a gynecologist needs to know to graduate her training today in 2026. No one taught them. So often will say something wrong or untrue or make the patient feel like it's all in their head. The Women's Health Initiative study (2002) misinterpreted data, leading to a press conference that wrongly claimed hormones cause breast cancer and cardiovascular disease, profoundly impacting women's lives for decades. We get no training in medical school, no training in our residencies, even gynecology and primary care.