#348 ‒ Women's sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Dr. Rachel Rubin, urologist and sexual health expert, covers women's sexual health, menopause's neglect, and hormonal decline. She clarifies perimenopause/menopause physiology, risks of untreated decline, debunks HRT myths, and guides personalized estrogen, progesterone, and testosterone therapy, highlighting safe local vaginal hormones.
Deep Dive Analysis
19 Topic Outline
Urology's Role in Women's Sexual Health
Menopause as a Castration Event: The Gas Tank Analogy
Perimenopause: Hormonal Chaos and Erratic Fluctuations
Physiology of the Menstrual Cycle and Hormonal Feedback
Varied Responses to Progesterone Decline and Supplementation
Health Risks of Not Taking Hormone Therapy Post-Menopause
Misinterpretation of the Women's Health Initiative (WHI) Study
Medical System's Failure in Menopause Education and HRT Training
Underappreciated Role of Testosterone in Women's Health and Barriers to Use
Systemic Bias Against HRT and the Rise of Unregulated Clinics
HRT Playbook: Progesterone and Systemic Estradiol Delivery Options
Navigating Hormone Lab Testing for Accuracy
Wide-Ranging Symptoms of Menopause Beyond Hot Flashes
Genitourinary Syndrome of Menopause (GSM) and Local Hormone Therapy
Benefits of Vaginal Estrogen and DHEA for UTIs and Sexual Health
Addressing Pain with Sex: The Vulvar Vestibule and Topical Androgens
Common HRT Concerns: Starting Late, Duration, and Cancer Risk
Finding Quality Menopause Care and Avoiding Exploitative Practices
Menopause's Impact on Men's Health and Longevity
7 Key Concepts
Menopause (Gas Tank Analogy)
Menopause is described as a 'castration event' where women's ovarian hormone production effectively ceases, similar to a gas tank going from full to empty, typically around age 52.
Perimenopause
This is a period of intense hormonal chaos before full menopause, characterized by erratic and unpredictable fluctuations in estrogen, progesterone, FSH, and LH levels, leading to inconsistent and often severe symptoms.
Luteal Phase
The second half of the menstrual cycle, following ovulation, where the shell of the ovulated egg (corpus luteum) produces a surge of progesterone, preparing the uterine lining for potential pregnancy.
Women's Health Initiative (WHI)
A large, randomized controlled trial from the early 2000s that studied hormone replacement therapy (HRT). Its results were widely misinterpreted, leading to widespread fear of hormones and a drastic decline in HRT prescriptions for decades.
Timing Hypothesis (HRT)
The concept that hormone therapy must be initiated within a specific 'window' (e.g., within 10 years of menopause or before age 60) to be safe and effective. This hypothesis is now being questioned by newer data and research.
Genitourinary Syndrome of Menopause (GSM)
The current medical term for the collection of symptoms affecting the genitals and urinary tract due to hormone loss. These include vaginal dryness, pain with sex, urinary frequency, urgency, and recurrent urinary tract infections.
Vulvar Vestibule
A highly hormone-sensitive tissue surrounding the female urethra, rich in both estrogen and testosterone receptors. It is often a source of pain during sex, urinary tract infections, and interstitial cystitis if not adequately supported by hormones.
14 Questions Answered
Men experience a gradual decline in sex hormones, whereas women experience a sudden and abrupt loss of estrogen, progesterone, and testosterone during menopause, akin to a 'castration event'.
During perimenopause, the ovaries are nearing the end of their egg supply, causing the brain to send erratic signals (FSH) to stimulate hormone production, leading to wild and unpredictable fluctuations in estrogen and other hormone levels.
Women not on HRT face increased risks of recurrent urinary tract infections, osteoporosis (with associated hip fractures), cardiovascular disease, dementia, and worsening mental health, joint pain, and overall quality of life.
The WHI study, despite its flaws and misinterpretation, led to a widespread fear of HRT, causing a drastic reduction in its use and a generation of doctors untrained in prescribing it, despite evidence of its benefits.
Testosterone is crucial for women's libido, genital and urinary tract health, and potentially mood, but its age-related decline is often ignored, and there are no FDA-approved products for women, creating barriers to its use.
The medical system struggles with humility, reluctance to evolve past outdated data (like the WHI), and a lack of funding and training for women's health, leading to a pervasive bias against HRT.
Red flags include doctors who only offer expensive, compounded products, require frequent, costly, and non-validated lab tests (like saliva testing), or promote 'pellet clinics' without FDA-approved female pellets.
Systemic estradiol can be delivered via patches, gels, vaginal rings (high dose), or oral tablets. Oral forms carry a slightly higher risk of blood clots and impact SHBG, while topicals avoid first-pass liver metabolism but can have adherence issues.
While symptoms are key, labs help guide treatment. Patients should insist on sensitive estradiol and testosterone assays (like LCMS) as standard ELISA tests can be inaccurate due to interference from other molecules.
Menopause symptoms extend far beyond hot flashes to include joint pain, frozen shoulder, plantar fasciitis, dry eyes, brain fog, ADHD-like symptoms, depression, anxiety, sleep issues, and changes in skin and hair.
GSM describes the symptoms of hormone loss in the genitals and urinary tract, including vaginal dryness, pain with sex, urinary frequency, urgency, and recurrent UTIs. Local vaginal hormones are crucial because they restore tissue health, acidity, and microbiome, significantly reducing UTI risk.
The 'timing hypothesis' suggesting a strict window for starting HRT is being questioned. While individual assessment is key, the benefits of HRT for bone health, vasomotor symptoms, and GSM can still outweigh risks, even for women starting later.
There is no data to support stopping HRT after 10 years. Discontinuing HRT can reverse bone density gains and may disrupt the body's equilibrium, leading to a return of symptoms and potential health risks.
Management requires careful, individualized discussion, focusing on shared decision-making. For BRCA patients without cancer, HRT may be considered to mitigate other health risks. For DCIS or treated breast cancer, emerging data questions the absolute contraindication of HRT, similar to how testosterone is managed in men with prostate cancer.
45 Actionable Insights
1. Use Local Vaginal Hormones
Use low-dose local vaginal estrogen or DHEA products (e.g., Intrarosa) to reduce the risk of urinary tract infections by more than half, alleviate vaginal dryness, pain with sex, urinary frequency, urgency, and leakage, as these are safe for almost everyone, including those with a history of blood clots or breast cancer.
2. Demand LCMS for Hormone Testing
When measuring testosterone and estradiol levels, insist on using the sensitive LCMS (liquid chromatography-mass spectrometry) assay, as ELISA-based tests are prone to interference from supplements like biotin and can yield meaningless results.
3. Progesterone Essential with Uterus
If you have a uterus and are taking estrogen, you must also take progesterone to protect the endometrial lining from hyperplasia and potential cancer, even if you don’t feel its immediate effects.
4. Avoid Testosterone Pellets
Avoid testosterone pellets due to the risk of super physiologic levels and irreversible side effects like deepening voice or clitoromegaly; instead, opt for reasonably dosed topical formulations for better control and safety.
5. Prefer Transdermal Estrogen
Prefer transdermal estrogen over oral estrogen, especially if you have risk factors for blood clots or prioritize sexual function, as oral estrogen can increase clotting proteins and sex hormone binding globulin.
6. Understand WHI Study Misinterpretation
Be aware that the Women’s Health Initiative (WHI) study, which caused widespread fear of HRT, was largely misinterpreted, leading to an entire generation of women being deprived of benefits and doctors being untrained in hormone therapy.
7. Recognize HRT Benefits (WHI)
Understand that the misinterpreted WHI study actually showed HRT decreased risks of colon cancer, fractures, diabetes, and overall mortality, with no significant increase in cardiovascular disease or breast cancer mortality.
8. Understand Menopause Inaction Risks
Recognize that declining hormones post-menopause, if left unaddressed, significantly increase risks for recurrent UTIs, osteoporosis, cardiovascular disease, dementia, and mental health issues.
9. Question HRT Timing Hypothesis
Question the ’timing hypothesis’ that limits HRT initiation after age 60; instead, engage in shared decision-making to consider HRT at any age based on individual symptoms (vasomotor, osteoporosis prevention, genitourinary syndrome) and health goals.
10. Don’t Stop HRT Arbitrarily
Do not stop hormone therapy after 10 years or at an arbitrary age without a specific medical reason (e.g., active hormone-sensitive cancer), as stopping can reverse bone gains and potentially cause other health disruptions.
11. Consider Testosterone for Women
Consider testosterone therapy for women experiencing low libido, increased UTIs, pain with intercourse, pelvic pain, depression, or anxiety, as levels decline from the 30s and global consensus supports its efficacy for low libido in postmenopausal women.
12. Apply Topical Testosterone (Women)
For women, apply a small daily dose (e.g., 0.5 ml ‘blob’) of 1% testosterone gel (like Testim) to the calf, and consistently use it for 3-5 months to experience its full effects.
13. Start HRT Low, Titrate Up
When starting hormone therapy, begin with a medium to medium-low dose and slowly titrate upwards as needed to avoid initial side effects like breast tenderness and improve tolerance.
14. Introduce HRT Hormones Sequentially
When initiating HRT, introduce hormones sequentially (e.g., estrogen first, then progesterone, then testosterone) rather than all at once, to better understand individual responses and manage symptoms effectively.
15. Use Labs to Guide HRT
While symptoms are paramount, use sensitive lab tests (like LCMS) to help guide hormone therapy, especially in perimenopause, as objective data can validate patient experiences and inform treatment adjustments.
16. Adjust Estrogen by Symptoms, FSH
Adjust estrogen dosage based on symptoms (e.g., breast tenderness indicates too much) and lab markers like FSH; if FSH is high and estradiol is low, and symptoms persist, consider increasing estrogen.
17. Educate on Menopause Symptoms
Educate yourself on the full spectrum of menopause symptoms beyond just hot flashes, as many doctors and patients are unaware of the wide-ranging whole-body effects due to hormone receptors throughout the body.
18. Address Brain Fog with Hormones
Consider hormone therapy to address brain fog, cognitive issues, and new-onset ADHD symptoms during perimenopause and menopause, as the brain’s estrogen receptors remain highly dense and even upregulate with age.
19. Address Joint Pain with Hormones
Consider hormone therapy to alleviate joint pain, stiffness, and improve recovery after exercise during menopause, as hormones act like ‘fluid’ or ’lubrication’ for the body, and their decline increases inflammation.
20. Consider Vaginal DHEA
Consider using vaginal DHEA (e.g., Intrarosa) for genitourinary symptoms, as it converts to both estrogen and androgens in the vaginal tissue, benefiting areas with androgen receptors and reducing UTI risk.
21. Compounded Topical for Vulvar Pain
For persistent pain with sex, UTI symptoms, or interstitial cystitis related to the vulvar vestibule, consider a compounded topical cream of 0.01% estradiol and 0.1% testosterone applied directly to the vulvar vestibule.
22. IUD for Progesterone Intolerance
If oral or vaginal progesterone causes severe mood issues (e.g., irritability, anger), consider a progesterone-coated IUD as an alternative to protect the uterus while avoiding systemic progesterone side effects.
23. Daily Progesterone for Sleep, Anxiety
For progesterone, consider starting with 100mg daily, or 200mg for 12-14 days cyclically; daily dosing often helps with sleep and anxiety reduction.
24. Progesterone Boosts Sleep, Hair, Mood
Be aware that progesterone, especially at higher doses like 200mg, can significantly improve sleep quality, thicken hair, and enhance mood for many women.
25. Vaginal Progesterone for Side Effects
If experiencing sedating side effects from oral micronized progesterone, consider taking it vaginally to potentially reduce brain exposure and mitigate these effects.
26. HRT for BRCA Post-Surgical Menopause
For BRCA patients undergoing surgical menopause without active cancer, offer hormone therapy to prevent shortened lifespan due to bone health and cardiovascular disease risks, as withholding it trades one problem for another.
27. HRT Post-DCIS Treatment
For women who have completed treatment for DCIS (Ductal Carcinoma In Situ) and are not on endocrine therapy, there is no reason why they cannot take hormone therapy.
28. Assess Absolute Breast Cancer Risk
When considering HRT, understand that the absolute risk increase for breast cancer incidence, even from the WHI study, was only 0.1% (1 additional case per 1,000 women), with no increased mortality.
29. Challenge Outdated Estrogen Warnings
Question the outdated and inaccurate box labeling on estrogen products that warns of stroke, blood clots, heart attacks, and dementia, as these claims are not supported by current data and may deter beneficial use.
30. Avoid Routine Endometrial Surveillance
Do not routinely seek endometrial surveillance (e.g., ultrasound, biopsy) for women on HRT unless they experience abnormal bleeding, as unnecessary procedures carry their own risks and discomfort.
31. Prioritize FDA-Approved HRT
Prefer FDA-approved hormone therapy products, which are well-studied and often covered by insurance, over compounded formulations like ‘biest’ due to lack of robust data on safety and efficacy.
32. Identify Exploitative HRT Practices
Be wary of doctors who dismiss HRT outright, push expensive or compounded products as ‘safer’ without evidence, or require costly, non-validated saliva testing, as these are red flags for exploitative practices.
33. Avoid Doctors Selling Hormones
Be very suspicious of doctors who directly sell hormones or operate their own compounding pharmacy within their practice, especially if they profit from these sales, as this can indicate exploitative practices.
34. Demand Evidence from Pellet Companies
Demand that testosterone pellet companies conduct FDA-approved studies to prove safety and efficacy for women, rather than relying on unproven claims or off-label use.
35. Find Qualified Menopause Practitioners
To find qualified menopause practitioners, consult websites like menopause.org (The Menopause Society) and isswsh.org (International Society for the Study of Women’s Sexual Health), and educate yourself through books and podcasts to advocate for your health.
36. Research HRT for Informed Decisions
Conduct your own research on hormone therapy, including resources like ‘Estrogen Matters’ by Avram Blooming, to make informed decisions about your health rather than relying solely on a doctor’s recommendation.
37. Assemble Your Healthcare ‘Pit Crew’
View your healthcare as assembling a ‘pit crew’ of specialists (e.g., sexual health, menopause, bone, heart doctors) rather than relying on a single physician, and make informed decisions based on comprehensive advice.
38. Support Women’s HRT for Male Longevity
Men should support women in seeking appropriate menopause care, as maintaining healthy partnerships through perimenopause and menopause can significantly impact male longevity and health outcomes by reducing divorce rates.
39. Evaluate Risks of Inaction
When making medical decisions, consider not only the risks of taking a medication but also the significant risks associated with not taking it, as these are often overlooked.
40. Understand Female Testosterone Dominance
Recognize that women typically have 10 times more testosterone than estradiol in their bodies (when normalized to the same units), underscoring testosterone’s significant, often overlooked, role in female health.
41. Regular Periods Don’t Guarantee Normal Hormones
Do not assume your hormones are normal just because you have regular periods, as testosterone levels, which decline with age, are not reflected in the menstrual cycle curve and can still be problematic.
42. Differentiate Estrogen Ring Types
Understand the difference between systemic (Femring, high dose, requires progesterone if uterus present) and local (Estring, low dose, no progesterone needed) vaginal estrogen rings to ensure correct treatment and avoid pharmacist errors.
43. Adjust Estrogen Ring Use
If using a 3-month estrogen ring and symptoms return in the last month, consider changing it earlier (e.g., every two months) or supplementing with a patch or gel during that period, despite potential cost implications.
44. Choose HRT Delivery Method Carefully
Select your HRT delivery method (patches, gels, rings, oral) based on personal preference, lifestyle (e.g., activity level, sauna use), and potential allergies to adhesives, as compliance is key for effectiveness.
45. Explore Sublingual Estrogen
Explore sublingual estrogen (placing an oral tablet under the tongue to dissolve) as a potentially cheap and effective method to increase estrogen levels without liver metabolism or driving up SHBG, similar to vaginal absorption.
10 Key Quotes
Menopause is sort of a, your gas tank is officially empty. There's not much in the tank. Perimenopause is this time where it's very erratic. The gas tank is over full and then it goes to empty really quickly without warning.
Rachel Rubin
The fact that this story hasn't been made into a Hollywood biopic megadrama, I don't know. This is a big deal.
Rachel Rubin
We scared an entire generation of people away from hormones because of a bad misinterpretation of statistics.
Rachel Rubin
Less than 6% of internal medicine, OBGYN or family practice doctors get even an hour of menopause education in their training.
Rachel Rubin
We are testosterone-driven beings. Both of us, right, are testosterone-driven beings.
Rachel Rubin
We're killing women by trying to protect them.
Rachel Rubin
I think I have more patients who never start testosterone therapy because of the fear of side effects than actually stop testosterone therapy because of the side effects.
Rachel Rubin
If a penis shriveled up at age 52, we'd probably have a vaccine sponsored by Pfizer.
Rachel Rubin
Viagra for women is vaginal hormones. What do vaginal hormones do? They relax the tissue. They increase arousal. They increase lubrication. They increase orgasm. They help with urinary symptoms. So they do everything Viagra does. And they prevent urinary tract infections. Viagra doesn't do that. So you're talking about better than Viagra.
Rachel Rubin
Menopause is killing men. It is killing men because it changes their marriages and it leads to divorce, which leads to death.
Rachel Rubin
1 Protocols
HRT Playbook for Women
Rachel Rubin- Start with systemic estrogen (e.g., patch, gel, high-dose vaginal ring, or oral) to address vasomotor symptoms, titrating up slowly from a medium-low dose to avoid breast tenderness.
- Add progesterone for uterine protection, typically micronized progesterone orally at 100mg daily (or 200mg 12-14 days cyclically), or vaginally if oral causes mood-related side effects.
- Consider a progesterone-coated IUD as an alternative for uterine protection, especially in perimenopause, as it also provides birth control and helps manage erratic bleeding.
- Add testosterone (e.g., 0.5ml of 1% Testim gel daily applied to the calf) if libido, energy, or other androgen-related symptoms persist, noting that noticeable effects may take 3-5 months.
- For localized genitourinary symptoms (pain with sex, UTIs, urinary urgency/frequency), add local vaginal estrogen (e.g., Estrace 0.01% cream) or DHEA (Intrarosa) even if on systemic HRT, as systemic hormones are often insufficient for local tissue health.
- For persistent pain with sex, particularly in the vulvar vestibule, consider a compounded topical cream of 0.01% estradiol and 0.1% testosterone applied directly to the affected tissue.