Episode Summary
In this comprehensive discussion, Dr. Lucy McBride interviews urologist and sexual medicine expert Dr. Rachel Rubin about the critical but often overlooked aspects of sexual health, hormone replacement therapy, and genitourinary syndrome of menopause. Dr. Rubin shares her holistic approach to patient care, explaining why sexual health should be treated like any other organ system and providing evidence-based solutions for common issues affecting both women and men. The conversation covers the biology of hormones, the safety and efficacy of various treatments, and the urgent need for better education among healthcare providers about these vital health topics.
Key Topics Discussed
The Importance of Comprehensive Sexual Health Care
Drs. Rubin and McBride emphasize treating sexual health as a vital sign, just like checking blood pressure or cholesterol
They advocate for creating nonjudgmental spaces where patients feel comfortable discussing intimate concerns
The conversation highlights how taking time with patients and asking the right questions can transform care
Dr. Rubin notes that sexual health problems are more common than diabetes, heart disease, or osteoporosis
The Bio-psycho-social Approach to Low Libido
Low libido affects approximately 40% of women, but only 10% are bothered enough to seek treatment
Treatment requires addressing both biological factors (hormones, medications) and psychosocial factors (therapy, education, relationship dynamics)
Antidepressants, while often necessary, can significantly impact sexual function for both men and women
The approach must be individualized, meeting patients where they are and addressing their specific goals
Testosterone: The Forgotten Hormone for Women
Ovaries produce significantly more testosterone than estrogen—about 10 times more when measured in equivalent units
Testosterone decline begins in a woman's 30s, contributing to low libido, urinary symptoms, and loss of muscle mass
Despite extensive safety data, no FDA-approved testosterone exists for women due to regulatory barriers and moved goalposts
Transdermal testosterone gel can be life-changing for women and for men, often taking 3-6 months to show full effects
Hormone Replacement Therapy: Safety and Efficacy
Transdermal estrogen (patches, gels, rings) is superior to oral estrogen for sexual function due to lower impact on sex hormone binding globulin
The Women's Health Initiative actually showed estrogen decreased breast cancer risk—it was never the problem
For the majority of women, the benefits of HRT outweigh the risks of HRT—if, that is, HRT is started within the first 10 years after a woman’s last menstrual period
The combination of estrogen, progesterone, and testosterone often provides optimal results for menopausal symptoms
Vaginal Estrogen: A Life-Saving Treatment
Low-dose vaginal estrogen reduces UTI risk by more than 50% and prevents hospitalizations and sepsis
The treatment costs only $13 per tube and lasts 2-3 months, potentially saving Medicare $6-22 billion annually
Proper application requires using a full gram of cream rubbed into vaginal walls, not just a pea-sized amount
The American Urological Association recently released guidelines confirming vaginal estrogen's safety and efficacy
Building a Healthcare "Pit Crew" for Sexual Health
Patients may need multiple specialists: sex therapists, menopause doctors, physical therapists, and sexual medicine experts
Dr. Rubin focuses on four key areas: libido, arousal, orgasm, and pain
The field of sexual medicine is rapidly evolving with new research, treatments, and educational opportunities
Healthcare providers need continuing education to stay current with evidence-based sexual health treatments
Key Takeaways
Dr. Rubin's advocacy work has led to significant policy changes, including new guidelines from the American Urological Association that explicitly state vaginal hormones are safe and effective. Her mission extends beyond individual patient care to systemic change through research, education, and mentorship. The conversation underscores that sexual health problems are treatable medical conditions, not inevitable parts of aging, and that patients deserve knowledgeable, compassionate care that addresses all aspects of their wellbeing.
The discussion emphasizes that while the field of sexual medicine has made tremendous advances, there's still significant work to be done in training healthcare providers and changing cultural attitudes about sexual health. Dr. Rubin's approach demonstrates that with proper education and tools, any clinician can effectively address these common but often overlooked health concerns.
You can find Dr. Rubin at www.rachelrubinmd.com!
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