Hello, my vibrant friend. Today, we are talking about a hormone that you might need at midlife or beyond. You will probably want to get this from your doctor. This is a special episode because this is one of those things that's vital for women's health, but not many people know about it. Neither might your regular doctor. Your gynecologist may or may not be aware of it depending on whether they're knowledgeable about menopause. Some urologists can help you with it, while some cannot. Therefore, finding a doctor who can guide you is crucial. Today, we have a urologist, Dr. Rachel Rubin, who will be joining the episode. She knows a lot about it. I trust what she says because the studies corroborate her views. What's wonderful about her is her vocalness about this issue on the internet. Let's enjoy this episode together. I want to share something that happened to me as well. I remember when I was about 50, I still had my periods, but my urinary system became rather erratic. The urgency to urinate was constant irrespective of whether I needed to go frequently or not. My teenagers simply quipped, 'Is this what happens when you turn 50?' They were correct. If I went to the grocery store, I felt the need to use the bathroom. The same happened when we visited someone's house. If my kids needed the bathroom, I would also accompany them. Like I mentioned, it felt urgent. My results ruled out a urinary tract infection. However, the changes made me susceptible to urinary tract infections as I aged. I'm going to leave it a mystery for a moment as we kickstart the episode with Dr. Rachel Rubin, but this is a really important episode, and I hope you will share it with friends and family. It affects you and your older relatives. I can't wait for you to hear what we have to unpack in the episode today.
Hello, my vibrant friend. Thank you for being here today on the podcast. I am thrilled to have Dr. Rachel Rubin with us today. She is a urologist based in the D.C. area and an outstanding doctor. If you follow her on social media, you'll know that today, we're going to discuss vaginal estrogen; she talks about it a lot because it's something we all need to be aware of. I did my medical training in the nineties. Back then, people used vaginal estrogen, but then Prempro was considered essential medicine for everyone. However, subsequent research indicated certain risks, leading to a shift in thinking - everyone needed to stop using it. After that, many doctors who weren't trained during that phase were unsure about the next steps. Thankfully now, some people are educating others about menopause, and urologists like Dr. Rubin also have a lot to impart. Both doctors and patients need to understand what's happening. So thank you for being here today, Dr. Rubin.
I am so thrilled to be here, and gosh, your patients and listeners are in luck. It's just an honor to be here.
Thanks. Please give my audience a brief introduction about yourself.
Yeah, so I'm Dr. Rachel Rubin. I am a urologist, but I did a fellowship in a field called sexual medicine. I deal with issues of libido, arousal, orgasm, and pain. A lot of midlife perimenopause and menopause folks approach me for help with one of these issues. I offer menopause care, hormone therapy, and evidence-based hormone therapy, both systemic - meaning for your whole body - and local. We're going to focus a lot on local vaginal hormones, which are safe and effective for almost everyone, and they prevent urinary tract infections and reduce sexual pain. It's honestly magical, but we can delve into the details later. Due to my training, I realized I could not only help one person in an exam room, which I do and spend a lot of time on, but I could also reach a lot more people by being outspoken on social media. I'm not concerned about how I look or sound. I just want people to get good information. Because of my approach, we've garnered a lot of attention and notoriety. I'm just excited to teach people what I know. What's cool is when people tell me, 'You helped my mom's friend, Dolores, who's been getting UTIs for years. I sent her your blog post or your Instagram page, and she got what she needed from her doctor. She's doing great.' Social media is an incredible way to provide valuable information to a large audience.
Well, I truly appreciate what you're doing. It really gets the information out there, and a lot of people are caught off guard by it. 'Oh my gosh, I had no idea.' So, how do I know if I need vaginal estrogen?
If you are a human and you have a vagina, you probably need vaginal estrogen. So, let's paint a picture for a moment. The genitals, the bladder and the vulva, let's say the pelvis, these areas are highly sensitive to hormones. For example, a baby girl has very low or no hormones, which makes her genital area appear red, raw, and irritated. She needs constant diaper changing becomes of frequent peeing, and cream has to be applied all over to soothe the pain. That's what non-hormonal genitalia is like. Then puberty occurs and the body transforms. The body grows labia, the tissue becomes pink, and it lubricates as well as acidifies, allowing tampons to be inserted, intercourse to take place, and babies to be delivered. The tissue changes and evolves because it possesses many hormone receptors, which include those located in the bladder, urethra, genitals themselves, and the pelvic floor. Teenagers tend to have potent sex drives as a result of the surge of both estrogen and testosterone. This also leads to other effects such as acne and oily skin. In perimenopause, the individual experiences hormone changes, including falling testosterone levels and erratic estrogen levels, which can affect the hormone-sensitive tissue. Doctors and individuals often do things to disrupt their hormone levels. We administer birth control pills, give spironolactone for acne, among other things to treat one issue, but it can exacerbate other problems. Some breast cancer treatments can severely affect the hormones in our bodies. Surgical menopause can also occur. As we age and enter menopause, our genitals which need hormones to stay healthy, lose those hormones. Like a plant withering due to lack of water, everything kind of shrivels up; it gets dry, irritated and scratchy. Pain during sex usually follows because there's reduced lubrication. People begin to observe their genitals in a way they never did before. What people don't often associate with menopause is the urinary frequency and urgency. 'I wake up at night to pee now,' or, 'I can't make it through this movie,' or 'I can't do a long drive anymore.' Such issues start to affect the quality of life. I couldn't wear the yoga pants I liked. Today, a lady in my office mentioned that it was too painful to do exercises with a pool noodle between her legs. It can affect both your intimate and your normal life. Today, a patient told me that even wiping hurt. Such occurrences illustrate what's called genitourinary syndrome of menopause. It's the genital and urinary symptoms that emerge as the body loses hormones. Local hormones play a vital role in nourishing the tissue and keeping it healthy, and this treatment is virtually safe for everyone. Adding local hormones to the vagina and the bladder are safe for people with a history of breast cancer, blood clots, or family history of such conditions. It's even safe for your 98-year-old great-grandmother in a nursing home. Urinary tract infections, which come with this dreadful condition, can seriously harm people and even prove fatal. Many patients land in the ICU needing IV antibiotics to treat infections that occur in the bladder due to the tissue not being strong and healthy. I know that was a long-winded answer, but I hope it was helpful.
No, I think that's really helpful.
No, I remember when I, you know, of course, I haven't practiced hospital medicine in years, but it was very common to see elderly women with a urinary tract infection, urosepsis, with their entire bodies affected, they were unconscious because of this infection. So how does this, the vaginal estrogen that we apply locally, how does that help with UTIs?
What happens is it's mostly a pH thing. Again, the tissue needs to be acidic to nurture a healthy microbiome. Several things are involved. Healthy bacteria need to proliferate, and harmful bacteria need to be suppressed; vaginal hormones enable the growth of those lactobacilli, those healthy, acidic bacteria. The thickness of the vaginal tissue, lubrication and elasticity all rely on estrogen and testosterone. We want an acidic, wrinkly vagina so that it can stretch, be strong, fight infections and make intercourse convenient if that's something you're interested in. That's why vaginal hormones can actually revolutionize the whole tissue structure and facilitate the prevention of infections.
Great. Let's talk a little about the benefits of sex. Pain, bleeding, you know, all of that. You must hear these stories frequently.
I hear such stories all the time. I'm a sex doctor, first and foremost. I deal with both urinary and genital symptoms. You could be a nun and still suffer from genitourinary syndrome of menopause because urinary frequency, urgency, and urinary tract infections are all associated with it. Certainly, if the tissue is dry, irritated and becomes very thin and flaky, we see decreased arousal and orgasm. Many women who used to experience phenomenal orgasms in the past complain that now their orgasms feel dull or take longer to happen. Evidently, pain with intercourse is something we see, which many women cope with. All of that is awful for your libido, right? If you're not getting much from sex and it's painful, why would you want it? So all of these symptoms are part of this localized genitourinary syndrome of menopause or GSM, as we call it.
So many doctors will simply say, 'Oh, you just need some lubrication for your menopause.' That's not going to take care of all those things you're discussing, correct?
It frustrates me when I hear that, in all honesty. Because when doctors read the guidelines, it recommends starting with lubricants and what we term moisturizers, which you can compare with moisturizing your face - you can apply a moisturizer on your vagina. And while they are excellent temporary solutions, and I'm not implying that you shouldn't use them - lubricant is always useful, it's wonderful, moisturizers work well - but they can't cure the problem. They simply put a short-term solution, a Band-Aid, on the issue. And we have safe, effective treatments available for patients that can rectify this problem. So why would you want to put a Band-Aid on an issue that it can't permanently resolve when we have the answer? Also, none of those products, the moisturizers and lubricants, have ever been demonstrated to prevent urinary tract infections. So, again, as a urologist, the thing I care about most is preventing death. The way I know I can prevent death is by preventing urinary tract infections. Rather than beginning this product after 10 urinary tract infections land you in the intensive care unit, I would rather start it when you're 45, and you're beginning to experience a bit of urinary frequency. This is because these products are so safe and they're so effective; I want to prevent it. Just like you're going to start your skincare regimen as early as possible to prevent those wrinkles, right? I want women to care as much about preventing vaginal, genital and urinary problems as they do about face changes.
Nice. So, in 2024, how are these applied? What's the procedure? How does it come?
It's fascinating because I just had a patient here who had tried a few products in the past, but she had stopped because nothing seemed to help her. And I said to her, I said, 'Nobody tries and fails vaginal hormones.' You have to find the product - it may not be your only problem. But it is the foundation. You can't fix all the other problems if the foundation is weak. And so you have to start with a healthy foundation. Just like you can't apply makeup without foundation. I'm not a makeup person, but you've got to start with the foundation, I know that much. The key is we have a few products and not every product works for every person. Someone might say, 'Oh, my doctor gave that to me, but it irritated me, or it was too messy and I didn't like it. I understand, but there are other types of products that we can use, which is encouraging. In few cases do women have choices, but here's a situation where we do have several choices. The most affordable option currently available is what's called estrogen cream. It's known as estradiol. It's a cream that comes in a tube and you measure out about one gram. This cream is applied in the vagina daily for two weeks, then twice a week for the rest of your life. One workaround to avoid the messiness and goopiness of creams is to rub it in, thanks to its absorption properties. When I tell patients, 'Just like you don't dollop on moisturizer on your face and then walk out the door, you rub it in,' similarly with sunscreen, you rub it in. So I'll tell them to put it in the vagina and then rub it in the wall so it absorbs and doesn't leak out; it's not messy it's a brilliant workaround. So that's the cream, which you can acquire for $20 per tube. Mark Cuban's online pharmacy or your doctor can send a prescription; they'll mail it to your house. Or, a good Rx coupon at your local pharmacy can usually get it for you about $20 per tube. Each tube lasts about 2-3 months, so it's accessible for everyone, and that's even outside of insurance. Many insurances will cover different products. So, there are vaginal estrogen inserts. One is called Vagifem or Uvifem they're tiny tablets that go in the vagina, and it's dosed out so you don't have to measure anything. And you put it in the vagina every day for two weeks and then twice a week for life. Again, if your insurance covers it, that's great. It can be a nice option. Sometimes there are other things we have to do if it doesn't solve all of your problems. But it's a really good foundational product. Then there's a great product on the market called Intrarosa, which is vaginal DHEA. If someone could hear me speak, I know I talk really fast, but I did say earlier that estrogen and testosterone are vital to this tissue. DHEA is actually the precursor for both estrogen and testosterone. So, by putting a DHEA tablet in the vagina, it converts itself and shapes a really nice environment that adds a little estrogen locally, a little testosterone locally. While it isn't enough to impact your entire body, it won't help with your libido or your skin or anything like that, but it's a fantastic product. It's been proven to prevent urinary tract infections as well. There's also a ring that can be inserted that remains in for three months at a time, which is great if you have a patient with dementia or poor dexterity who can't put something in the vagina. These are all the local options. There's one pill called Osphena, that you take every day. It's a SERM, which I don't want to explain in detail, but it works very well. If you're worried about a person with a history of a blood clot or something like that, you might want to be cautious with one of those products, whereas the other products are very local.
That's great. I appreciate you telling us about all the different ways because midlife women are probably thinking about themselves, but they also have parents or grandparents. It gives you an idea that there are alternatives if you're concerned, 'oh gosh, I can't imagine doing that with my grandmother.' There might be a comfortable option with one of these tablets.
It could save your grandmother's life. This is vital; too many older women die of urinary tract infections, and no one is offering them this life-saving preventive strategy.
Right. That ring sounds very easy to use since it's not something that has to be dealt with daily.
It is actually wild how many little old ladies die from urinary tract infections, and nobody is offering them this life-saving preventative strategy.
Right. And that ring, that sounds very easy as well because it doesn't, it's not a daily thing anymore or, yeah. So how do we know this is safe? How do we know it's not absorbed?
Yeah, there's a number of studies that have come out, and even more recently, that shows when you draw someone's blood in menopause, their estrogen is gonna be, like, less than 5, you know, is, is the sort of the value of estrogen, and sort of a man's estrogen is 25. So it's, again, a low level of estrogen, but it's enough to keep a man's bones healthy and brain and libido healthy, so, you know. That when you use a vaginal estrogen product, your blood levels of estrogen and testosterone don't increase past the menopausal range, right? It stays in that normal, low range. So there's not a whole body absorption to any measurable degree over time that could increase, you know, stroke, heart attacks, blood clots, dementia. There's just no way. And studies have shown that there is no risk of stroke, blood clots, heart attacks, dementia. We even have studies that show people who use vaginal estrogen live longer from a cardiovascular perspective than those who don't. And I think it's about inflammation, right? If you can decrease inflammation in your body, you're going to live longer. If you're using vaginal hormones, maybe you're still sexually active, which means that you're still active, which means that again, you can live longer. And so, it's safe. There are so many studies. This has been around since the 1970s, and all studies show that it is safe. The one patient population where we still need more research and that some people pause is women with breast cancer.
That's great. So people need to talk this over with their doctor.
Never have a doctor just tell you no. Right? You really need to understand it and have what we call shared decision-making, because what you want and what your goals are really matters. It's not for me to tell you what is right or wrong, good or bad. We have to understand what, what are your goals.
And I'll tell people too, like I, you know, at menopause time brought up this discussion with my primary care doctor, and she said, 'I'm afraid of hormones.' And I said, 'Okay, end of discussion.' I, and I went and found someone else who wasn't afraid to talk about these things. So, you know, if a doctor tells you this, you might need another doctor as well.
You have to know that not one doctor knows everything. Right? I, all the time, will say, 'You know what? This isn't my expertise. I need you to see a cardiologist. I need you to see someone who specializes in connective tissue disorders.' So, unfortunately, we love doctors to say, 'Oh, hormones, those are dangerous. You can't have those.' That's not acceptable. There is nobody who can't have, you know, like this idea of shared decision-making and really understanding the pros and cons. The risks and benefits are really clearly shown to you. And then you understand that your doctor can't possibly know everything just because they're a gynecologist, they don't, they were never taught about menopause, which is a nightmare, but the truth.
Yeah, so let's bring up a couple of things. A couple of things you said brought up a few questions for me. So this may make your sex life better, but it may only be a piece of it, right? If, if things are kind of going downhill with menopause. Can you talk about that a little bit?
So it's important that people understand. You know. I love what I do because I, I deal with couples. Right? As a urologist, I can treat men, I can treat women. I can treat any triangle that comes to my office. And I love sex because it's so complex, it's so biopsychosocial, right? I need to know your past, your background and how you feel and what's happening for me to help, right? And so, there is so much biology. Remember we talked about those horny teenagers a moment ago? The horny teenagers are not having deep, meaningful conversations. I promise you that. Right? There is a hormonal component to libido, specifically in teenagers. And so hormones matter. Dopamine matters. There are biological components to libido, to sex drive. There are hormonal components and blood flow issues to arousal. Orgasm is a fascinating biological topic in which a big reflex and a neurological feeling of pleasure. And so, it's really fascinating. And also, I have to take the partner into consideration as well. How you were raised thinking about sex, what your goals are. So, therein lies the fact that it's not just here, take this estrogen and you'll be fine, and everything will be better, but you really have to work with someone who's going to get to know you and to be able, I would say it's like tinkering. We have to get it right for you because you are not like your friend, and the things that you care about. And if I have a patient who comes in and says, 'I love sex. I love my partner. I've had the best sex life in the world... until menopause happened.' Well, that is a different benchmark than the person who comes to see me and says, 'I've never liked sex. I've never been interested in sex. I don't want anything to do with it. I'm not bothered by it.' Those are two completely different treatment strategies. Right? And so you have to be, you have to work with a doctor who's going to actually get to know you to say, 'Well, maybe we'd be more aggressive in the libido department,' or, 'Hey, I see you have a lot of trauma in your history. Let's work on the hormonal piece, but also work on the mental health piece. And I've got this great referral for you of this great person who's going to work with you on all of that.' I love this job because I take care of your vagina and your clitoris, not just the penis, but the, the, really your whole person, which makes my job just, just so joyful.
Even though we're not going to, this is probably its own podcast episode, but trans people need to know that life transitions are still going to happen for them, right?
Transgender people will still have some changes at midlife that may need some changes, right?
It depends. Right? It totally depends. Some people have their ovaries removed, some people have uterus removed. So, it really becomes getting again, understanding your medical history, absolutely, and what it's doing and what you want it to do, and that's why, again, you need a team because usually it's not going to be... not all transgender doctors are sexual medicine doctors. So, you really have to sort of dip a toe outside of your normal team to say, 'Okay, I actually need some help on the libido side,' or 'I need some help on the pain side.’
Great. That's great to hear. Now, if people are already on hormone replacement therapy, they have a patch and a pill. Does vaginal estrogen play into this at all?
Huge. It's a really important question and thank you for asking it. So I would say, I don't have a number for you, but I would bet that the majority of patients on hormone therapy are not being screened or checked for genital and urinary symptoms. And so if you say, 'Oh, I'm on hormones,' but you're still having frequency, urgency, pain with sex, urinary tract infections, dryness, vaginal hormones are very important to your hormonal therapy. And so we have to think of it as sort of the package of hormone therapy should always be something locally, something systemically, protecting your uterus with progesterone if you are on whole body estrogen. Now, when you're on just local estrogen, you do not need progesterone. And, and then that testosterone component for the whole body becomes important as well and is really not talked about enough.
Great. Thank you so much. I appreciate everything that you managed to say today. People need to hear it, and, and not everybody knows it. It's kind of one of those basic things that, that not enough people know about, right?
You know, what I've learned recently is that it's not about saying new things to old people, but it's about saying old things to new people because this is so basic. This is so simple, and yet no one's doing it, and not enough people have access to the information, and people are dying because of it. And so, again, vaginal hormones have been around since the 1970s, and we have a marketing problem. We are not marketing it correctly. We are not offering it like, you know, we have, this should be Viagra for women. I mean that very seriously. What does Viagra do? It increases arousal, it improves erections, it improves sexual health for men. It's a blockbuster. Vaginal estrogen, or DHEA, improves arousal, improves orgasm, improves lubrication, helps with sexual function, and also prevents urinary tract infections. You're talking about a product that improves sex, to the level of Viagra, and prevents UTIs, which cost our healthcare system millions and billions of dollars and cost the lives of many, many people. And it's not a blockbuster. It's not in the hands of every person who needs it. This, my friends, is a marketing problem. This is a misogyny problem. This is a huge problem, and that's why we speak about it so loudly, because what I'm saying is not complex. It's not difficult. It's not something that you didn't have in your fingertips in the 90s. Right? When you were in practice and in medical school. And so why do we suck at this so bad? And it's a marketing problem, which is why I try to market loudly and will talk to anybody who will listen.
I so much appreciate that about you. Thank you so much for being here today.
Thank you for having me.
Yeah, and Dr. Rubin is live in practice in the D.C. area. So, tell us a little bit about that.
Yes, I started my own practice two years ago. We're officially two years old yesterday. I am building my dream practice of where you come in; we spend time with you. An in-person visit is an hour and a half. You get a full exam where you get to really get educated on how your body works, and we get to know you and figure out what your goals are. And we deal with a lot of complex patients who come from all over the world. I'm building a team of doctors who are so knowledgeable and invested in this. I'm going to train the next generation of people who do this. And so we're really having a good time. I would love for people to follow along on social media @DrRachelRubin, I'm sure it'll be in the show notes. And our website is We have a great newsletter that goes out at RachelRubinMD.com.
Great. Congratulations on the two years in the practice. It's such a, such an important thing.
Thank you so much.
And thanks for being here