Dr Rachel Rubin: Women’s Sexual Health, Menopause, Hormone Replacement Therapy (HRT), and Orgasms!
Sexual medicine specialist Dr. Rachel Rubin, a board-certified urologist, discusses the overlooked crisis in women's sexual health, detailing hormonal impacts on libido, the truth about HRT, and physical blockers like clitoral adhesions and pelvic floor issues. She emphasizes education and communication for better intimate health.
Deep Dive Analysis
32 Topic Outline
The Crisis in Women's Sexual Health
Doctor Training Gaps in Women's Health
Understanding Female Anatomy and Hormones
Testosterone's Role in Women's Libido
Impact of Birth Control and Medications on Sex Drive
The Menstrual Cycle and Hormonal Fluctuations
Perimenopause: Symptoms and Early Changes
Hormone Replacement Therapy (HRT) Explained
The Misinformation Surrounding HRT
Four Types of Hormone Therapy
Vaginal Hormones for Bladder and Genital Health
Understanding and Preventing Urinary Tract Infections (UTIs)
When to Consider Hormone Therapy
Addressing Pain During Sex
Fundamentals of Great Sex: Financial Literacy Analogy
The Pelvic Floor and Sexual Function
Understanding Female Orgasm and the Clitoris
Clitoral Adhesions and Orgasm Improvement
Role of Sex Toys in Female Pleasure
Men's Misconceptions About Female Arousal
Post-Orgasm Experience for Women
The Impact of Pornography on Sexual Expectations
Healthy vs. Damaging Pornography Use
Spontaneous vs. Responsive Sexual Desire
Communication and Vulnerability in Relationships
Addressing Sexual Discrepancies and Kinks
Faking Orgasms and the Orgasm Gap
Stress, Dopamine, and Libido
Scheduling vs. Spontaneous Sex
Self-Esteem and Body Image in Sex
The Importance of Biology in Women's Health
Communication as the Crux of Relationship Health
8 Key Concepts
Genitourinary Syndrome of Menopause (GSM)
A condition where hormonal changes, typically during perimenopause or menopause, affect the bladder and genitals, leading to symptoms like pain with sex, dryness, urinary frequency, and UTIs. It can also occur during lactation.
Clitoral Adhesion
A condition where the hood of the clitoris gets stuck to the head, preventing full exposure of the clitoris. This can diminish sensation and make orgasm more difficult, affecting about 23% of women.
Pelvic Floor
A group of thick muscles that form the base of the pelvis, supporting organs and attaching to the genitals. Issues with these muscles (tightness, weakness) can cause pain during sex, affect arousal, and impact orgasm.
Responsive Desire
A type of sexual arousal where a person's desire for sex increases once sexual activity or foreplay has already begun, rather than being spontaneously present beforehand. This is common in women.
Spontaneous Desire
A type of sexual arousal where a person experiences a sudden, unprompted urge or desire for sex, often without any prior sexual stimulation. This is more common in men.
Orgasm Gap
The observed disparity in orgasm frequency between men and women, with women orgasming less often than men. This gap is often attributed to a lack of education about female anatomy and pleasure, particularly the clitoris.
Vaginal Microbiome
The community of bacteria and other microorganisms residing in the vagina, which is crucial for maintaining an acidic environment that protects against infections like UTIs. Hormones like estrogen and testosterone help maintain its health.
Perimenopause
The transitional period leading up to menopause, typically starting between ages 35-45, characterized by fluctuating hormone levels (especially progesterone and testosterone) and various symptoms like sleep disturbances, anxiety, fatigue, and irregular periods.
11 Questions Answered
Many doctors, including gynecologists, lack adequate training in female sexual health, hormones, and anatomy, leading to misdiagnosis or dismissal of symptoms, even for affluent women.
Combined birth control pills suppress ovarian function, reducing the body's natural production of estrogen, progesterone, and testosterone, which can lead to decreased libido in some women.
Testosterone, often considered a male hormone, is crucial for women's libido, arousal, orgasm, satisfaction, and can also positively impact body image, with levels starting to drop in a woman's 30s.
HRT involves giving back hormones (typically estrogen and progesterone, sometimes testosterone) to manage symptoms of perimenopause and menopause, addressing issues like hot flashes, bone loss, and low libido.
UTIs are caused by bacteria in the bladder, often due to an imbalanced vaginal microbiome. Vaginal hormones help maintain the vagina's acidic environment, which supports healthy bacteria and significantly reduces UTI risk.
No, sex is not supposed to be painful. If a woman experiences pain during sex, it indicates an underlying issue such as hormonal changes, skin conditions, tight pelvic floor muscles, nerve problems, or scar tissue, and requires medical investigation.
Most women orgasm through clitoral stimulation, not penetration, because the clitoris is the primary organ for female pleasure, and it is largely an internal structure not directly stimulated by penetration.
Mainstream pornography often caters to male demand, creating unrealistic expectations about female pleasure, body types, and performance, which can lead to misunderstanding, dissatisfaction, and a decline in intimacy in real-life relationships.
While spontaneity is often idealized, scheduling sex can be beneficial for busy couples, especially as relationships evolve, helping to create dedicated time and space for intimacy and excitement.
Low self-esteem and negative body image can be significant blockers to great sex, leading women to feel undeserving of pleasure or uncomfortable with intimacy, regardless of their body type or weight.
Education about biology and open, vulnerable communication between partners are fundamental for understanding and addressing sexual challenges, fostering empathy, and building stronger, more intimate relationships.
15 Actionable Insights
1. Advocate for Your Sexual Health
Actively seek out doctors specializing in sexual health or pelvic pain, and don’t hesitate to get multiple opinions, as many general practitioners lack training in these areas.
2. Understand Your Anatomy
Learn about your own body parts, including the clitoris, vulva, and urethra, as basic anatomical knowledge is crucial for advocating for your health and understanding pleasure.
3. Consider Vaginal Hormones for Symptoms
If experiencing urinary frequency, urgency, leakage, UTIs, painful sex, or dryness, discuss vaginal hormones (estradiol cream or DHEA inserts/rings) with your doctor, as they are safe and highly effective.
4. Address Clitoral Adhesions
If struggling with orgasm, ask a specialist to examine your clitoris for adhesions, as a simple office procedure to remove them can significantly improve arousal, orgasm, and satisfaction.
5. Prioritize Pelvic Floor Health
If sex hurts, orgasm is weak, or arousal is diminished, consult a pelvic floor physical therapist to assess and address muscle tightness or weakness, as healthy muscles are crucial for sexual function.
6. Evaluate Birth Control’s Impact on Libido
If experiencing low libido while on combined birth control pills, discuss alternative forms of contraception with your doctor, as these pills can lower testosterone and impact sex drive.
7. Explore Testosterone for Libido
For postmenopausal or perimenopausal women with low libido, arousal, or orgasm, discuss testosterone therapy with a knowledgeable physician, as it can improve sexual function and body image.
8. Talk Openly About Sex
Engage in open, curious conversations with your partner about what great sex means for both of you, what you enjoy, and what you want to explore, as communication is fundamental to intimacy.
9. Challenge Pornography’s Influence
Recognize that mainstream pornography often misrepresents female pleasure and can create unrealistic expectations; focus instead on understanding your partner’s actual anatomy and desires.
10. Schedule Time for Intimacy
Combat modern over-scheduling and the ‘spontaneity myth’ by intentionally scheduling time for connection and intimacy, like quarterly ‘spouse days,’ to foster joy and desire.
11. Address Underlying Stress and Burnout
Acknowledge that chronic stress, overwork, and lack of sleep significantly impact libido and sexual function; prioritize self-care and white space to improve overall well-being and sexual desire.
12. Reframe Body Image for Sex
Challenge the belief that you must be ‘skinny’ or perfect to deserve great sex; everyone deserves intimacy, pleasure, and connection regardless of body type.
13. Consider Orgasm First for Women
Focus on ensuring the woman achieves orgasm first, as it can lead to pelvic floor release, make penetration more pleasurable, and potentially allow for multiple orgasms.
14. Understand Arousal Differences
Recognize that women are often more ‘responsive’ in their arousal (getting aroused once sexual activity begins) compared to men’s more ‘spontaneous’ arousal, which informs foreplay and initiation.
15. Engage in Post-Sex Debriefs
After sex, have a conversation with your partner about what went well, what didn’t, and what you might want to try in the future, just as you would for other important activities.
9 Key Quotes
The word clitoris today in 2026 does not exist in the checklist for what an OBGYN has to learn in their training.
Dr. Rachel Rubin
Menopause is a castration event.
Dr. Rachel Rubin
We don't make you go blind completely before we give you eyeglasses. We don't let your kidneys run out completely before we give you dialysis or medications to help your kidneys along.
Dr. Rachel Rubin
Sex is not supposed to be painful. If sex is painful, you need to figure out why.
Dr. Rachel Rubin
Women are not orgasming as much as men. The data is very clear there. And I think the majority of problem is education.
Dr. Rachel Rubin
Communication, it's probably the most important thing. Can you talk about it? Can you use words? Can you explore? Can you ask questions?
Dr. Rachel Rubin
If you're only able to do something in one way, in one position, watching one specific thing, that may not translate into great intimate sex with a partner.
Dr. Rachel Rubin
People are having less sex than ever. People are not connecting. People are scrolling, and they're on their AI chatbots instead of, like, human connection. We're getting worse at this, not better.
Dr. Rachel Rubin
It's not me against her or her against me. It was me and her against the problem.
Steven Bartlett
4 Protocols
Vaginal Hormone Application (Estradiol Cream)
Dr. Rachel Rubin- Take one gram of estradiol cream on your fingers.
- Rub it inside the walls of the vagina.
- Rub it on the outer area at the opening as well, like applying sunscreen.
- Apply twice a week.
Vaginal Hormone Application (Tablet Inserts)
Dr. Rachel Rubin- Use the provided applicator to insert a small tablet into the vagina.
- Press a button on the applicator to release the tablet.
- Apply twice a week.
Vaginal Hormone Application (Vaginal Ring)
Dr. Rachel Rubin- Insert the ring into the vagina, similar to a tampon.
- Leave it in place for three months.
Vaginal Hormone Application (DHEA Suppository)
Dr. Rachel Rubin- Insert the DHEA suppository (Intrarosa) into the vagina.
- Apply every night (or potentially twice a week).
- Allow it to melt at bedtime.