Dr. Rachel Rubin
Appearances
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Oh, it's absolutely life changing. A third of the patients are like, I don't really notice. It doesn't bother me. I'm fine. But if you tell me I need to take it, I'll take it. If you tell me I need to take it to protect my uterus, no problem. And then you've got a third of patients who are very sensitive. And even within that third, it is extreme.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I mean, we see progesterone allergies where people have horrible reactions to it makes me too sleepy. It makes me feel bloated. I don't like this. And so I don't as a clinician and an interested researcher, like I don't know exactly enough to be able to spot who those people are ahead of time.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So I think this is a really important question in the sense of what is the risk of taking hormone therapy in that patient? And what is the risk of not taking hormone therapy in that patient? And so I think it's super interesting because we love talking about the risks of medication, but we don't spend a lot of time talking about the risks of not taking medication.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So if we think about that woman as she gets older, she certainly will have the microbiome and genital and urinary changes of not having hormones. So as a urologist, this is actually one of the couple things that will kill her.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
As you lose hormones in the genitals, which are very hormone sensitive, the bladder is very hormone sensitive, you change the microbiome, you decrease the acidity of the tissue, the bad bacteria grow, your risk of urinary tract infections increase drastically. So she may get recurrent urinary tract infections or pelvic pain.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
She may develop osteoporosis, which we know more people die of hip fractures, about the same die of hip fractures as die of breast cancer. So the risk of not taking hormone therapy when you get a hip fracture, as all of your listeners know, going back to the life that you lived is very challenging or you die. There's also the risk of dementia and Alzheimer's much higher in women.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And we can argue the data. And I don't think we actually have good data about whether hormones, when to start them and if they're actually protective and how they're protective. But we also know that heart disease is the number one killer of women. And we know that things get worse as you get older. So I think there are significant risks to that person. And from the mental health perspective,
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think there's no question that we see worsening. Now, I will say perimenopause, from what I understand of the data, is actually worse on mental health and can actually level out a little bit once there's less erratic hormones. But again, an empty gas tank is still an empty gas tank. And so we see a lot of challenges in this time period.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The fact that this story hasn't been made into a Hollywood biopic mega drama, I don't know. This is a big deal. A billion dollars of our resources went into doing this study. And there are many things that we learned that were helpful and useful and this huge set of data that we're still using today to extrapolate information from. And there was a lot of good that came from it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But there was a lot of misinformation and just really bad marketing or really effective marketing, you could argue. Because what is so wild, Peter, is that when this study came out, they did a press conference. Before the study was published, they did a press conference. Have you ever seen the NIH do a press conference that Matt Lauer talked about or that was made it on Good Morning America?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They did a press conference. I remember I was in medical school at the time. Like, I remember this happening. And they said, OK, we had to stop the study early. It is increasing the risk of breast cancer and increasing the risk of blood clots and cardiovascular disease. And we have to stop the study.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There's different statistics out there, but people will say about 40% maybe of women were on hormone therapy at the time. Overnight, it crashed to nothing. You're talking billions of dollars of an industry went to nothing. And the people who are prescribing the hormone therapy were like, this doesn't make any sense. I do this. I've been doing this for 20 years, 30 years.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I don't have a clinic full of people who are dying of blood clots or heart attacks or who get breast cancer. Like this is not my clinic. Whose clinic is this?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Then they published the paper, and as we talked about before we did this podcast, is that they misinterpreted the data so drastically and scared everybody with so much fear that you actually have an entire generation that has forgotten how to prescribe hormone therapy. And this is the nightmare that we're living in today because now we realize that the data was misinterpreted.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the WHI was one medication, one dose. That's it. And it was a sort of birth control pill style kind of hormone therapy. So a synthetic estrogen and progestin. It was not the, what we call more, and we can talk about the marketing term bioidentical, but the FDA approved products that we use today, like estradiol and progesterone, they're different medications that we use today.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so you're talking one medication, one dose, and we're still practicing fear-based medicine 30 years later, whatever it is, saying like, we don't practice any other medicine like this. We're like, Well, there was one study about surgery 30 years ago, and that's the way we practice medicine. We evolve, we learn new things. So what did it show? Let's talk about the good.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When you took estrogen and progestin or estrogen alone, you had a decreased risk of colon cancer. You had decreased risk of fractures, like significant decrease of fractures. Decrease of diabetes. Okay, that seems like a good, those seem like all good things. This is in the hormones we don't even really prescribe anymore.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We saw a decrease in overall mortality, a decrease in cancer-specific mortality. And then when you looked at the cardiovascular data over time, and again, I'm a urologist, I'm not a heart expert, but you saw there was actually no difference. It actually wasn't so scary. Now, as you get older, we know birth control pills can cause blood clots.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So we do worry about giving a birth control pill to grandma because you can increase blood clots. That's true. I agree with that. When it comes to breast cancer, the most fascinating data that didn't make the press conference, women who are on the estrogen alone, so they didn't have a uterus, so they didn't need the progestin therapy, had a decreased risk of getting and dying from breast cancer.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it didn't make the news. Even in that study that put the box labeling on all the products, it's not true. So then when you looked at the estrogen and the progestin groups, there was a fear that there was an increased risk of incidence, but not mortality from breast cancer. And even when you look at that data, there is questioning of the fact that the placebo group
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
actually was more protected by breast cancer because many of them had been on hormones in the past. And when you use a correct placebo group, the lines actually go together. And so you're more of a statistics nerd than I am, but the reality is there was no difference. And so we scared an entire generation of people away from hormones because of a bad misinterpretation of statistics.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Shout it from every rooftop you can find.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You are not going to get pushback from me on that. This is a disaster. I just got back yesterday from teaching at the largest internal medicine conference, ACP, the American College of Physicians, and you're talking more than 20,000 internal medicine physicians. What a wonderful thing. I was asked to give a course on female sexual dysfunction, and it was wonderful. I talked a lot about menopause.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There was no other menopause content at this course. There was no courses, how to prescribe, given everything you've done, my colleagues and myself have done to bring it into just popularity. Patients are coming in asking questions, and there wasn't even a course to learn about I can't say that's true for GLP-1s or any of these lipid-lowering agents or all of the things that you've been pushing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The problem is you now have a brain drain, I think, because the doctors who prescribed hormone therapy either retired or died, and there was no one they taught ahead of them. Now, I was very lucky. I had very good mentorship and incredible experience, but we are now trying to make up for lost time to train people how how to write prescriptions.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So it's not enough to say, hey, the WHI was misinterpreted and we've done a bad thing for women. People don't know how to do this. It's a huge problem. And the reality is this is half the population. This is not niche medicine. The fact that menopause medicine is the tiniest little room of subset of gynecology, which it should not be under gynecology. This is whole body medicine.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And yet nobody seems to care.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, I mean, the data is very clear on this. Less than 6% of internal medicine, OBGYN or family practice doctors get even an hour of menopause education in their training. Do you remember learning about menopause in your medical school? Zero, not one minute. I didn't learn one minute of it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Oh, yeah. So because you are taught hormones are dangerous or the bodybuilders take the hormones, the snake oil salesmen take the hormones. We don't talk about this in real medicine. Everyone says it's not my industry. It's not my thing. I went to this internal medicine conference yesterday and all the internal medicine doctors were saying, but this isn't my field. I don't feel comfortable, right?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I am so thrilled to be here. I have been nervous for quite a long time, but I'm super happy to be here.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
An endocrinologist was standing there saying, I don't feel comfortable doing this. I said, you're a hormone doctor. That is what you do. It is so embarrassing. I've been asked to speak at multiple academic centers to teach on hormone therapy. And every time I'm like, is this real life? I am a urologist teaching hormone doctors about how to prescribe hormone therapy. And it is real life.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And this is why I'm so loud about it, because we have to change this. We have to change this on a big level because I need the ICU doctors and the pulmonologists and the heart doctors and all the doctors to know that menopause affects their organs. Colon cancer. Why aren't GI doctors talking to women that estrogen prevents colon cancer? Why are we checking DEXAs at 65?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Why are rheumatologists not prescribing hormone therapy? I found out recently that psychiatrists, because I do a lot of teaching about how to prescribe hormone therapy. A few of us are very passionate about it. And I was like, sit with me. I will teach you how to write the prescriptions.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I've had psychiatrists tell me their malpractice insurance will not cover them if they prescribe hormone therapy. And I said, wait a minute. You prescribe postpartum depression drugs, which are progestin based. You do reproductive psychiatry, which means birth control is a part of what you do.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And you're being told you're not allowed to prescribe hormone therapy when hormone therapy is one of the greatest antidepressants in the history of medicine. It is insanity. We're living in a nightmare.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Super interesting, and I'm very passionate about this topic. And so I think it comes from this idea that I do testosterone for men all the time. I'm very confident. I love prescribing testosterone for men's sexual health. And actually, very interestingly enough, when we prescribe testosterone for men, remember, their gas tank doesn't get empty. It gets low. It's off-label.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We are doing off-label testosterone therapy in men. Unless they have Klinefelter's or some significant medical problem, we're doing off-label testosterone for men. And it's very understood. It's talked about. The FDA just three weeks ago removed the labeling on testosterone therapy, saying it no longer is a cardiovascular disease risk. So that's great news.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the thing about women and testosterone is it's actually not a menopause thing. Testosterone is an age-related decline. So in your 30s, you're starting to drop your testosterone. And testosterone, I don't know who decided that men get testosterone and women have estrogen. Like we both have both of the hormones.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Way more. And I love sharing that. When you put everything in the same units, we are testosterone-driven beings. Both of us, right, are testosterone-driven beings. We don't teach this to OBGYNs. No OBGYN knows, some do, but very few know about the role of testosterone in women's health. And so we love to gaslight women and say, well, if you have your period, your hormones are normal.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Drives me insane. Women are told this all day, every day is, well, you can't possibly have a hormone problem because you're getting your period regularly. And the reality is, is that's not true. Why? That curve, that curve we were just talking about, testosterone is nowhere on that curve. And so we know there's a peak of testosterone around ovulation.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
That is nature's way of saying, let's make a baby. We know that. We know that your libido goes up around ovulation because your testosterone goes up. And so there is this age-related decline in testosterone. And here's another big problem. We give women birth control pills all the time. How does birth control work? By the way, birth control is high-dose hormone therapy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We love hormone therapy and birth control, but as soon as you become menopause, everybody's afraid of hormone therapy. It makes no sense. So birth control is high-dose, I would argue, the hormone therapy we're talking about in the WHI that is more synthetic, that has side effects, that have issues like that.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So birth control turns off your ovaries, and it adds back a final estradiol and a synthetic progestin. It doesn't add back testosterone. So we are botching testosterone for women along the life cycle, to be honest. But if you take someone who's never been on birth control, their testosterone starts to drop in their 30s. So what are they complaining about? It's not just a libido thing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We know there are testosterone receptors all throughout the genitals and the urinary tract. So we see women have an increased risk of UTIs. We see an increased risk of pain with intercourse or pelvic pain conditions. We see there are some studies that indicate potentially depression and anxiety can increase because we do think there's a testosterone effects on the brain.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yes, but what you forget, Peter, is that urologists are ultimately the quality of life doctors. We deal with urination problems and we deal with sexual medicine, right? No one cares about erections and orgasm and libido quite the way that a urologist cares about. And when we're board certified, actually, it's not a gender thing. We're not penis doctors only.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But we have global consensus. And I don't know if you've read the news lately, Peter, but we don't agree on too much as a globe. But there is global consensus that testosterone in women works for low libido. And so specifically, the data is on postmenopausal women. That's where the global consensus is. But there is data in perimenopause and much smaller studies before that.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The consensus is it works. But everyone has emotions about testosterone. I didn't think testosterone was a feeling, but apparently it is a feeling for people because people hate talking about it. And again, nobody taught you how to prescribe it. And there's no FDA approved product for women, except in Australia, it's approved by their governing body.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so you have a lost art of knowing how to give people back testosterone when they are symptomatic.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I love talking about this and I'm actually grateful for celebrities because just in the news in the past few weeks, Halle Berry says she's on testosterone. Kate Winslet says she's on testosterone therapy. They look pretty amazing to me and they don't look androgenized at all. And so I actually want to do this study.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's something my research team's working on is 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. That's my observation in doing a lot of this. Now, when we talk about side effects, I tell them, think about a horny teenager.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They have these great libidos, but they have some oily skin, acne. But that's when you get really high with your doses. We really don't see it clinically. Yes, I use FDA approved testosterone for men, just a dose is one tenth a dose in a way. They rub it on their leg because if they do get hair on their leg, people are used to having hair on their leg.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so they shave it, they wax it, they laser it, whatever it is that they do with leg hair. I don't have that many patients stop for acne, oily skin. I think there's that fear when you get really high in the dose. So I'm not a pellet promoter or user because you get super physiologic levels and I can't take it out if you get a pellet put in.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so if you have deepening voice or clitoromegaly hair issues, these are the challenges with some of these super physiologic levels. But when we're using reasonably dosed topicals, we really see magic happen.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And I can't tell you, when we get estrogen and progesterone right for our patients, it is by adding that third piece, that testosterone, because your ovary probably does more than three things, but at this point, estrogen, progesterone, and testosterone, when we add that testosterone piece, it's wild. All the patients come back and they say to me, wow, I feel like me again. It's wild.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We're board certified to take care of everybody's genital and urinary tracts. Unfortunately, society has led us to know a lot more about the men's sexual health and men's genitals than female genitals. And so my background, I trained in urology really because I was interested in women's health, but I also was interested in sexual health, sexual medicine. And I didn't like delivering babies.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
That's the piece, wow, I didn't realize how badly I felt. Wow, that was the missing piece. I hear it over and over and over again. I can't not want that for all women. I can't not want to give them that as an option on the menu.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, that's typically how we do it and how our guidelines look at it. So ISWISH, the International Society for the Study of Women's Sexual Health, fabulous organization. You can find any doctor to help you with menopause and sexual health by going to their website. They came out with a really lovely... how-to practice guideline that they took from the Global Consensus.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And they do recommend using that FDA-approved testosterone for men and using it at appropriately doses for females. So I like Testim, which is sort of the 1% generic testosterone gel. I'll show it to you. I brought it for you to show you. It's a five milliliter tube of gel. Our male patients would use the whole tube of gel, rub it on their chest every day.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I have very few men who do that, by the way. Injections, orals, those are much better. And so I tell my patients, use a blob or a 0.5 ml so they can put it in a syringe if they want to and dose out that 0.5 ml. They take a blob. They rub it on their calf every day. And so just don't use the whole tube should last you about a week or 10 days. It's an ish.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's not an exact precision science, but the patients can figure this out. It's not that challenging. I will say this, and I think I have colleagues who disagree with me on this, and I would love to know your experience. I think testosterone, I think for men too, but that's my bias, it takes a while to kick in.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I will tell patients, you need to do this regularly, and I think it's going to be three, four, even five months before you're going to really wake up and say, wow, this is working. Oh my gosh, someone just walked across the street and I did a cartoon style head turn with my eyes popped out of my head. Oh my gosh, I initiated sex. Wow, that orgasm was easier to have.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
These are the things that patients notice. I also get patients telling me their stress incontinence is slightly improved. Why? Because the urethra has testosterone receptors in it. We know that for all genders. These are the kinds of things my patients will report. I don't know. What do you think? I think it takes a while.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We have studies on testosterone, which show... Oh, sorry. I mean, within my observation. Got it. I hear you. Yes.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's getting harder and harder to find these days. And so I think similarly, we've been interested in it and people have played with it before. This idea, can you do one squirt into your... Nobody likes to squirt things in their nose, it turns out. It's a challenge. Now, any of these topical testosterone formulations, a lot of them have alcohol in them.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So I don't recommend putting them on your genitals directly. But I do think it needs to be studied. It's challenging finding the formulation of testosterone that is low enough, like from the male side, because we have lots of formulations for men that is low enough to kind of give an appropriate dose.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I didn't like OBGYN. It just didn't fit well with my personality. And what I love about urology is that we can see everybody and we can really dive deep on quality of life issues. And the magic of urology is also that you really get to know your patients. It's not like when you did surgery, you take out someone's appendix and you never see them again. Maybe you do one post-op visit.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Buckle up, buttercup. So here we go. We had a billion dollars that was put into it. A billion dollars and a five-year study that was done at the FDA. And it showed it was safe. It showed that it was effective. It showed that it was... The TLDR on testosterone is it's not that serious. We want it to be serious. Again, not a feeling. We want it to be like all about aggression. It's not a feeling.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It truly isn't. So they did five years of study. A billion dollars went into it. And the FDA came back and they said, ooh, women have breast tissue. So we're going to need five more years of data and another billion-dollar study. And every company was like, I'm out. The benchmark was different for women.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. They just keep moving the goalpost. Everywhere they move the damn goalpost. Okay, I talked about the labeling on testosterone being removed, that it doesn't worsen cardiovascular disease. Why? Because they did the Traverse study that your listeners know about. That proved it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The box labeling on estrogen products, which says that estrogen causes stroke, blood clots, heart attacks, probable dementia, we just got done saying that that study didn't show that. So why is that box labeling still there? We're killing women by trying to protect them.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think medicine has a humility problem and a deeply ability to say, hey, we didn't know what we didn't know back then. We're learning and we're adjusting. They don't like to say, I don't know. They don't like to evolve in their thinking. And for some reason, women's health comes with so much bias. The amount of money that goes into women's health research is worse than it was 10 years ago.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I wake up in the morning and I'm like, how is this real life? Okay, I'll give you an example. We met with the chief before the administration changed. We met with the, I think it was the chief medical officer of the FDA. We met with someone high up at the FDA. It was a room full of perimenopausal women. I was like, yeah, we got this. It's
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
a room full of perimenopausal women, and we presented our case about vaginal hormones, which is basically microdosing hormones, and they prevent UTIs by more than half. When you use vaginal hormones, you treat the genitourinary syndrome of menopause. And we said to them, we said, your labeling, this should not have the same labeling of all estrogen products. You should remove the labeling.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And they said, well... we're really gonna need industry to come at us to remove the labeling. I said, you didn't need industry to put the box on. Why do you need industry to remove the box? We no longer have industry in this field in any significant way because the WHI destroyed that industry. So we have a huge problem where you actually don't have any money to women's health.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think Pfizer completely fired their women's health division saying, yeah, we're gonna look at allergy now. You have entire departments. We did a study once on pelvic pain We were looking at botulinum toxin and pelvic pain. And I was on the call where they said, oh, we have a new CEO now and women's health is no longer a priority. Like I heard those words. So we do have a paternalistic problem.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Urologists have deep relationships. We're both surgeons, but we actually care about the medical side of these quality of life issues. And so as I was going through medical school, I really realized that talking about sexual health, quality of life issues, that was fun for me. I was good at that. And in medicine, you gravitate towards what is easy, not what is hard. And so it's just been a joy.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's true. And unfortunately, it's not getting any better.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The Traverse Trial, right? Yeah. There were two bad studies that were done, horrible studies that made no sense, that showed testosterone had some dangers. The FDA threw that box labeling on, said, oh, my gosh. Within minutes, they created the Traverse Trial. It got done in five years.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And within minutes when it was finished and it got published in the New England Journal of Medicine, the box was removed.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Totally. Look at data. Oh, there was an increased fractures from the testosterone causes fractures. That makes no sense. We know that's not true. We know testosterone helps bone mineral density. And so you can make the same arguments of how you look at these studies, how these studies are designed, the flaws of them. You're going to do a study for five years. Why are you giving people gels?
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Is that the right thing? So why do we care? what the people of the Women's Health Initiative said 20 years ago. Why is that even news? And why can't it die? And because you don't have enough people like you standing up, you don't have the internal medicine doctor standing up and saying this is wrong because they're not teaching it.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You don't have the OBGYN saying this is wrong because they're delivering babies and women are dying in childbirth. Women's health, menopause health in particular, is important to nobody. When it's nobody's problem, nobody takes ownership of it.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
No, we can't. And it's so fascinating because I would never, I do sexual medicine, so I look at the whole patient, I look at everything, and I would never say to them, hey, you have to stop this beta blocker right now because it's causing your erectile dysfunction.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And really, I've been working to further the field of urology to make us better at taking care of women. And so really, I do a lot of educating and teaching to my colleagues about how we really need to care about the whole, like everybody.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I would never tell a patient that, though the beta blocker may be worsening his erectile dysfunction, but I would never say, stop this medicine. It's hurting you. I would talk to their doctor. I would have a conversation. But there's something about hormones that doctors who know nothing feel very confident in saying, you can't be on this.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You must stop this without even having that curiosity of, huh, I wonder if the person who prescribed it actually knew what they were talking about. And it is everywhere. We see this all the time.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So I would argue that people care about their pain points. People want to feel better. People will go to anyone who tells them there's a whole supplement aisle at CVS that makes all these wildish claims that we're going to help you with everything.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And the reality is, is I just got done saying your gynecologist and your internal medicine doctors are going to, in that 10 minute visit, tell you that you don't need this. This is not going to help you. And so enter the fringe people, the snake oil salesmen, the people who are doing wildly inappropriate things. That doesn't mean the hormones themselves are bad.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It just means we have a marketing problem here. If we're not doing it and helping people, they hear their friend did it, they hear their neighbor did it, and they said, I want what she's having. This is why we call ourselves the menopause. This is why we teach so loudly.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
is because we're trying to bring it back into medicine and evidence-based medicine and say, you can actually do this quite reasonably. In fact, there are many FDA approved products that work much better, that are more regulated, that are totally safe. Here's what they are. They should be covered by your insurance and giving them that knowledge. Because the problem is, is it's too quiet.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
No one is giving people answers. No one's even looking at the questions. So then the fringe people take over and are unfortunately doing a very inappropriate thing. You know what? Men's health too.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
As a urologist, we see shot clinics and all these wild PRP clinics and testosterone pellet clinics and compounded pellets and all of these things because my colleagues, we are not doing enough to take care of men's sexual health. And so these clinics exist to prey on those patients who deeply want to connect and get their answers.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
which is why my colleagues and I are even loud about it for everybody.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And you know what I say? I say, you know, with these things is the people who need it are not being offered it. And the people who don't need it are abusing it. And that is true for hormones for everybody. I talked about this at the last menopause meeting. Less than 4% of women are on hormone therapy right now. Less than 4%.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Less than 4%. That's worse.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's worse than 10 years ago. It is so bad out there. I did the same calculations you did when I was on my Uber on the way over. I said, how many women are over 40? It was something like 84 million, according to AI. And there are about 3,000 people on the Menopause Society website. That doesn't mean everybody knows what they're doing or that they all do the same thing.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But divide 84 million by 3,000, it's a big number. And we can't see patient panels of 27,000 people. The math doesn't math there. So we need people to step up. So who should be writing estrogen prescriptions? Who?
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Every doctor who sees a woman of that age. And so who actually does? Nobody.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What's lovely is we need a toolbox because not everybody responds to the same thing. I love micronized progesterone. I think it's a fabulous product. It's my go-to first line. Sometimes we need to put it vaginally instead of orally to help with some of those sedating side effects. So you can avoid going to the brain if you put it vaginally. And so we do find that cuts down.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I typically start orally.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Depending on your dose of estrogen. I typically start with 100 milligrams. Some people say if you're going higher with your estrogen, you may need to do 200 milligrams of progesterone. That data is not very clear. And there's really two ways to give progesterone. You could do it every single day, so typically 100 milligrams every day.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And then some people in a lot of data shows if you do it cyclically, like 200 milligrams 12 to 14 days out of the month is another way to do it. Both are fine. When we see many patients, they feel better doing it 100 every day because it can help with sleep and anxiety reduction.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think there is not enough data there and we need more. I think if patients bleed, it's a nice tell that maybe they need more progesterone.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think there's some interesting that I've learned that some people say if you take it with fat or you take it with something to eat, it absorbs better because progesterone is not absorbed very well, which is why we always had synthetic progestins in the first place. And so we're still learning the capabilities of micronized progesterone.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But according to most menopause specialists out there, they typically will use 100 milligrams every day or 200 milligrams 12 to 14 days of the month.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They love you forever. It is so fun to get to see.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
No question.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You can do either. You can say, hey, try taking this vaginally and see if that goes away. See if you're no longer feeling anger or bloated or have irritability. And so vaginally can be an option. We love progestin-coated IUDs. They're great in perimenopause. Why? Because people think that you just lightly dance into menopause. It is like bloody murder hell scene. It can be terrible.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You can bleed the whole month. You can bleed heavy. You can bleed when you're least expecting it. So the IUD is very nice because it will stop bleeding. And so you throw an estrogen patch on and some testosterone, and that's a really great perimenopause plan. And you get birth control. And you get birth control, which is very important.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You can add micronized progesterone to the patient who gets good sleep, even if they have an IUD. That doesn't add danger. We love that. So we love IUDs for this population. There's another synthetic progestins, which you can use as well. I've seen people do things like Slind, which is a birth control, a progestin-only birth control pill, add a patch in testosterone to that as well.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now, again, synthetic progestins sometimes can have mood side effects as well. So they're not completely benign for all people. There's another, I don't know if you've used this at all in your practice, it's called Duave. Have you heard of this? It's an oral estrogen, but it also has what's called basodoxafine, which protects the uterus, but is not a progesterone-based medicine.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I wish they were separate. I wish we could just give basodoxafine alone. Any pharmaceutical reps? so that you don't have to use oral estrogen if you don't have to. Oral estrogen is not evil. I'm a sex doctor, and we know that transdermal is a little better for sexual function. So that's, again, why I'm a big fan of transdermal products as well. But that's kind of another option.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
People get hysterectomies for lots of reasons. We've had patients do that who really don't tolerate progesterone, and then you can just use estrogen only.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We really don't like to look for things. The nice thing about endometrial cancer, from what I understand, again, I'm putting my urology hat on. I am not a gynecologist. It bleeds. Now, if you bleed, then if you bleed and you just started a new hormone therapy, it's probably okay. Now, for me, I like to know if there's any structural things going on. Do you have a polyp? Do you have a fibroid?
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Is your lining super thick? If you're in perimenopause, you still should be bleeding. So it's that challenge. I don't go looking for things that aren't bleeding because I don't necessarily want to find things.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So no, at this point, there's not necessarily a reason for routine surveillance because if your lining is say six millimeters and you're not bleeding, are you really going to put that woman through a biopsy and through a hysteroscopy? And those have significant pain and problems that go with that as well.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I like to start one before the other in general because I like people to know what's doing what.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When someone comes to see you and says, give it all to me, it's always a disaster. Every time. One time it worked well for me, but it's pretty much a disaster. So I like to stack it. And again, you're not going to cause endometrial cancer in three months of using just estrogen. I mean, you're talking something that takes years and years and years to develop.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And even that data is not that clear cut. So I'm not worried about me causing a uterine cancer. Now, often we'll start with the estrogen. Sometimes you'll start with progesterone if sleep is the major issue, but I find the vasomotor symptoms, it's such a big deal to get rid of those. So I do like often starting with estrogen and then slowly adding in the other ones.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I certainly did my research and I am not a car person, but I know you are a Formula One guy. And I got a very interesting email last week that said, Dr. Rubin, my wife is seeing your practice. Her libido is now like an F1 Formula One race car and I'm like a 1988 Honda Civic. What can you do for me? My analogy I really like to look at is sort of the gas tank analogy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You said it right there. I think that what happened is the Women's Health Initiative happened and hormone therapy all went into the underground. Went to the alley. It went to the alley. And I think one of the ways that these back alley doctors did it was saying, oh, we're using the safer version.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We're using this compound and we're going to make it 80-20 and we're going to use the more safer option. By the way, I haven't seen that data and there is no data on biased in large trials that's going to really tell me what it does. And we're going to just use this. And that's what got people through for a while. And I don't... Actually blame those people if they had no alternative.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If I were in the middle of the desert and I had the options and I was having horrible symptoms and I had the options of nothing or a biased cream, I'd probably slather the biased cream on me. Where we are now, we have lots of options. We have FDA approved options and they're covered by insurance most of the time. So I don't prescribe it because I haven't needed to.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now, if I have a patient who comes into me and they're feeling great and they have no problems, do I have to change them? Well, I'll say, well, do you want to save some money? Like we could change you to a different formulation. That's an option. Sometimes I'll even check if, say, they're having symptoms, we'll check their levels.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And I don't know if you find this, but their estradiol level is essentially zero. It's less than five. And I'm saying, listen, I think you're just using fancy lotion. I think you're paying a lot of money to put nice lotion on you. And I don't know that it's protecting your bones.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And if we're using this to protect your bones or to stop your hot flashes or to help with your sexual health, maybe we use the formulations that are a little bit better studied and that I know are absorbing in your body because I can prove it. And what's your take on that?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This idea that men, as they age, sometimes we see a decrease in their gas tank. They're feeling low. They're feeling down. They've got erectile dysfunction, low libido. Whereas women at age 52, their gas tank is empty. This is a castration event. We don't have many castration events in men's health. And so menopause is sort of a your gas tank is officially empty. There's not much in the tank.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When I teach this, and I do a lot of teaching of physicians holding their hands saying, you can do this, you can write these prescriptions. And one of the things that I just keep coming back to is the sentence, what are you afraid of? And I love that because when someone says, well, can I do it in this patient? Well, what are you afraid of? Can I use this product? What are you afraid of?
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it forces, I think in menopause medicine, the reason we're all struggling is is we're not yet at an algorithm or a playbook, as you say, that it's a one size fits all. What's so sexy about this field is we actually have to use our brains. We have to use our brains. We have to talk to people. We have to get to know what's bothering them.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And we have to do the right tools for them, which may be different in each person. Because you have to also understand what are your patients afraid of? Because that is the only thing that matters. We take risks all the time. I took a risk taking a car to get here. We take risks. If you ever drink alcohol, you are taking a risk.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We all take these calculated risks and we all have different calculations. And so I love to push people of, well, if you were to use this, so patient comes in unbiased, is that safe? Well, what are you afraid of? Am I afraid I'm going to hurt this patient? I don't think I'm going to hurt them necessarily, but I don't know what's in that compound.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I don't know if the top of the bottle is the same as the bottom of the bottle. I don't know if it's good for her bones. I don't know if it's absorbing in the way that it should be, but I do have studies on FDA-approved estradiol. And then it becomes, what am I afraid of with the patients? Well, what are you afraid of about the estradiol? Are you afraid of cancer?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Because you know that in the Women's Health Initiative, people who used estrogen had a decreased risk of getting and dying from breast cancer. Our patients don't know this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
A little bit of nomenclature here. There is systemic estrogen. So when we're talking about hormone therapy, whether you call it hormone replacement therapy, the new way we talk about it is menopause hormone therapy, or if you want to just say hormone therapy is totally fine. We're talking about hormones for your whole body.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Estrogen for your hot flashes, for your bone protection, for your skin, hair, and nails, that's estrogen. That's systemic estrogen. But there's this whole other topic, which I hope we talk about later because it's my favorite one, which is local vaginal hormones, which are to treat the genital and urinary symptoms of menopause. And those are pretty much safe. No, I'm going to say it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They are safe for every human on earth, including your 99-year-old mother-in-law in the nursing home who potentially could die of a urinary tract infection. So this is kind of the two separate areas. And I think the question you're asking me is, let's talk about systemic estrogens.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Because I got a lot to say about that one. So systemic estrogen has a toolbox. We have patches. We have gels. We have rings, which go vaginally. We have oral estradiol. Those are the big ones. There are injections. That's kind of an old school way that I use sometimes, injections of estradiol, Valerate or Cipionate. And so each one has pros and cons.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
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. And so I like that analogy because I think it's helpful when we're talking to women about the reason you don't feel like yourself is because there's just no gas in the tank.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it's nice to have the toolbox because not every product works for every patient. And the key is, is getting it right for that patient because you need something that they're going to do and that they're going to do it for a long time because these are not things that you just do for a weekend.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I don't use it much, but that's not to say that it isn't useful. I think it is actually very useful. I think it's underused. For example, people are used to taking birth control pills. They're used to taking pills. They like pills.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
doing for a healthy person with no major risk factors of cardiovascular issues, taking an oral estrogen really is not going to increase your risk of blood clots or heart attacks or anything like that at any significant worrisome level.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Less. It's less.
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#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I tend to always start transdermal. And again, this is my sex doctor hat because we learned from this study called the KEEPS trial where they looked at oral estrogen versus transdermal estrogen. And it's a fascinating trial. But in that trial, they found that, yes, there's a slight increase of blood clots with oral estrogen, but sexual function is better in transdermal.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And that's because of what happens to sex hormone binding globulin. So when you take oral estrogen, we talk a lot about first pass metabolism through the liver. It goes through the liver, the liver, lots of things go through the liver when you take medications. And this one in particular, it can pump out more clotting proteins.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So if you're at any risk of blood clots, just like birth control pills, if you're a smoker, if you are overweight, if you have a genetic predisposition to blood clots, we're not going to use an oral hormone product. Now, I want to paint this because this is actually an area where I would love to see research.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I was speaking at a Harvard testosterone course with Abe Morgan Tyler and Mo Cara, who you've had on the show, and I was speaking about women's testosterone use. And the speaker who got up there to talk about transgender hormone therapy talked about sublingual estrogen. He kept referring to sublingual estrogen. And I ran to the microphone. I said, What are you talking about?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So we see the ovaries are no longer producing estrogen, progesterone, and testosterone the way that they were during your reproductive years.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I've never heard of sublingual estrogen. There's no product. What are you saying? And he says, oh, you just take an oral estrogen tablet and you put it under your tongue like a tic-tac and you let it dissolve and it doesn't go through the liver and it works fabulously to increasing blood levels. And I said, oh my God, this sounds amazing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Presumably, because it doesn't go through the liver, which actually, if you think about it logically, I love logic here because we don't have a lot of data, so we love logic. I said, well, if you take an estrogen ring, a high-dose estrogen ring, and you put it in the vagina, same thing. You absorb estrogen vaginally. What's the difference there, right? A sublingual estradiol.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So I think it's fascinating. I don't have many patients on it, but I would love to see data look in that direction because it's cheap. Oral estrogen is cheap. You get lots of doses. You can dose it
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You can get away with a lower dose. Absolutely.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Again, I don't have patients on this and I haven't seen any studies on this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, absolutely.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Again, transgender hormone therapy uses much higher doses. So my guess is one or two milligrams BID is probably what they do. If I were playing with it, I would probably be nervous and I'd probably do 0.5 check levels and I'd do twice a day. Again, this is not what I do in my clinics. But just as we think through, what are you afraid of? What are you afraid of with this?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's pretty fascinating stuff.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's not that serious.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But it is true for men and testosterone. We often find the topicals do not. Some they absorb beautifully and you get these beautiful levels and they feel great. And then you do have a population that just doesn't absorb well through the skin. And unfortunately, we don't know who those people are. I always tell patients, here's the menu and we're going to tinker.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We have to tinker to get it right for you because you're not like anybody. And so patches, a lot of people have heard of patches. They like patches. They make twice weekly patches and they make once weekly patches. I find the twice weekly patches are much better tolerated and my patients like them better. What's nice about patches is you have a wide variety of doses that you can play around with.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When I start patients on hormones, I typically choose like a medium to medium low version because if you go too high initially, they get breast tenderness and they get really annoyed with you and then you have to backtrack. So I always like titrate up a little bit as we need to. So patches are nice, but for some people, they don't stick well. For some people, they don't absorb well.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
For some people, they feel that they kind of drop off. If you change it twice a week, they feel like they're getting a little lower.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. And there are people who are allergic to the adhesives. We see that as well. So some people, they love patches. Again, you have to have a menu. If you're going to a doctor and they give you one type of hormone therapy and that's the only type, please run. They need to know the menu because it's not a one size fits all. So there's gels and there are a number of different gels.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There's gels like the brand name is Diva Gel goes on your thigh. There's Estrogel, which goes on your arm. There's Eva Mist, which is a spray, sort of an aerosolized spray that goes on your arm. Gels can be really nice because it's every day. So it's dosing every day. The challenge is sometimes they take a little bit to dry.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So if you're a busy person and you want to rub something on and you want to run out of there, I find gels, not everybody wants to do something every day. You got to get to know the people. What do you like to do? What's your routine? You have to get it into their routine. And sometimes you got to work up to it. And sometimes I have patients, they'll use patches.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But when the summertime hits and it's hot and muggy, they'll switch to the ring or they'll switch to a gel.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Oh, so I love the ring. There's two types of ring. Now, this is important because your pharmacist sometimes messes this up. So there are two FDA approved rings. Now, a ring, just like a birth control ring, you set it and forget it. You put it in the vagina. The vagina does not feel it like a tampon. You don't feel it. And it just stays in for three months at a time.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You just kind of push it in there and it just settles in and finds a place. By the way, if you have penetrative sex, most people don't take it out. They don't feel it. Nobody's bothered by this thing. So this ring goes in there, stays in for about three months. Now there is a fem ring, which is a high dose ring, which means if you have a uterus, you need progesterone to protect the uterus.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it comes in two doses, 0.05 and 0.1. Then there's an E-string, which is a two milligram localized estrogen ring. You do not need progesterone if you have a uterus because it's just treating the genitourinary syndrome of menopause. So it's not treating your hot flashes. It's not protecting your bones. It's not going to help your night sweats, but it's going to prevent UTIs.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's important that you know the difference because the pharmacist sometimes won't and he'll give you the wrong ring, which could be catastrophic if they think they have a systemic ring, but they have a local ring.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, they look a little different.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The reason one is systemic is- It's a high dose and one is a low dose.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, both three months.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Both three months. Now, there's a company right now studying a product. I'm not at all affiliated, but it is a one-month ring that has both estrogen and progesterone in it, which is very interesting. And I'm curious to see where the research goes with that. It's a one-month ring. So the issue with the ring, I love the ring.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now, there are women who you show them and they're like, no, I don't want that. There are women who've used rings for birth control. They love the idea. I will tell you, and we've been hoping to publish on this clinically. Again, I don't know about you, but my patients don't listen to the book. They don't read the book and they don't follow the FDA curves. But my patients, it peters out.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It literally stops working that last month. How long? Everyone's a little different, but I have patients where that last month they are dragging. Their hot flashes come back.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's expensive. So a lot of times insurance doesn't cover the ring. It's about $180 cash price when you use an online pharmacy called Transition. It's expensive. Sometimes they'll slap a patch on or a gel at the time to sort of overlap. So they'll change it early or they'll add a different therapy or they'll stop using the ring altogether. It is perfect for like two months. And we'll check levels.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Again, there's the book answer, the Instagram answer, and the Dr. Rubin answer. This is where checking levels is actually helpful.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's incredible because you will see it. You'll check it. You have a 0.1 ring in and you should expect estrogen levels of 60, 70, something like that. And you'll see an estrogen level of 13 and you'll be like, oh my God, this is not working, right? And they'll complain of hot flashes, night sweats, their symptoms will come back. And so we see a lot of ring issues with dosing for that purpose.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And then another problem is if you have any kind of prolapse. So as people have babies, things can kind of prolapse. And so the ring can fall out during bowel movements, other things like that, if there's not enough space in there. So I had an ultramarathon runner.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It looks kind of like the stock market. Actually, it goes up, it goes down. And it's not even just checking it every three months. If you check it every 10 days, you're going to see a fluctuation. I'm obsessed with looking at the menstrual cycle. I'm obsessed with talking about numbers here because it is so fascinating and we are not taught to think this way.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It gets expensive. This is where checking levels is beautiful. Marathon runner comes to me. She loves her ring. She's doing great. She messages me, oh my God, I feel awful. Something's not right. I don't feel like myself again. I said, oh, where are you in your ring? Where are you in the cycle of your ring? We talk about it. I said, let's just check a level, see what's happening.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Sure, estrogen was undetectable. I said, okay, we need to change this ring. And she messaged me, I can't find it. She can't find the ring. It's not there. She probably had a bowel movement. It fell out. She didn't notice. And then her levels dropped. So it's where that detective work helps you kind of figure out what's going on with your patient.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the ring is not perfect for everybody, but I love the ring. If you're in perimenopause and you have an IUD, a ring, you put a little testosterone every morning. It's really a set it and forget it. If you get vaginal estrogen, systemic estrogen, you get your progestin from the IUD, you add a little topical testosterone.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. And not expensive. Like you can do it relatively inexpensively.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I typically get the sensitive estradiol level. Yeah, that's what we get for everybody. Same with the testosterone assays.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So we're going to get a lot of hate. There's a lot of disagreements when it comes to hormone therapy, how to properly do hormone therapy, how to check for hormone therapy. And one of the places, and it's funny because I truly believe, and for anyone who's going to say mean things about me on the internet from this podcast, I truly believe that actually most of us agree on like 98% of this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Truly, we want women feeling better. Most of us believe the data that hormones, the benefits outweigh the risk. And so I think 98% we agree. There's the 2% where there is disagreement, and part of it is also in the what we don't know yet, the unknown and the curiosity and sort of things. And lab testing is one of those issues. The book says never check labs.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so I have a lot of curiosity about it. So, for example, when you're in your, let's call it healthy reproductive years. And by the way, nobody is the book. You talk a lot about continuous glucose monitors. I would love continuous sex hormone monitors. And unfortunately, I know there'd be a lot of unintended consequences and bad things that would come of it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If your doctor checks labs, they are really doing something wrong. You should only care about symptoms. And then you have sort of the fringe that are doing all saliva based testing every minute, check labs, do all these expensive labs, which I do not agree with. Again, the Instagram answer, the book answer, the Dr. Rubin answer of sort of there are reasons to check labs. And I do find labs.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Similar to you, my curiosity with labs is so fascinating. When you can capture this perimenopausal fluctuations and show the patient the reason you feel so terrible is because your estrogen was 1,000 and now it's zero and that hurts. Now, do I need numbers to know that that's what's happening? It actually helps patients quite a lot for them to look at this and see the data.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What is your take on that?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But I'd be very interested because the book says are low. So if you have your period that you're bleeding, that's day one. your low is not zero. In fact, it's probably somewhere 40, 50 is probably what the low should be of estradiol. And that's picograms per milliliter, as opposed to testosterone, which we do nanograms per deciliter, as you know. So let's say 50 is your low.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You've seen all my gray hair that I've grown. It's true. I find, again, that humility of medicine is I am famous and my patients love me because I spend a lot of my day saying, we don't actually know. This is a data-free zone. Here's what I think. Here's how we're going to use logic. Here's the tools in our toolbox.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But there is that ability to really know the data so well, to truly understand what's There's a lot we need to figure out. And that's why I have a research group. And that's why we're trying to answer these questions, because we have more questions than we have answers. But I also need to get my patients feeling as good as possible. And that is addicting, to be honest.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I love that. And I think it's such a reasonable and logical, the logic there, it makes so much sense to me. So we're totally in line with that. And that's why, again, it's very confusing for our patients on social media, because they want the exact answer. And you're not going to find your exact answer from one doctor on social media.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Oh my gosh, you said that I have to use an estrogen gel, but I use a patch. Should I switch to a gel? Again, it's not that serious. There is a menu if it's working for you and you feel like you're getting what you need. Now it's good to get educated and learn about all the different options so that you can see what's right for you.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But I think expecting that one doctor gives you all the answers is not going to happen.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We haven't spent a lot of time really talking about the symptoms of menopause. What are we treating? Why do people need systemic therapy? I'm often saying that menopause has the worst PR campaign in the history of the universe. Why? Because we think it's for old people and we think it's just hot flashes and we think hot flashes go away. There's actually not enough education.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Like we can argue about E1, E2 and E3, but the reality is doctors don't even know the symptoms of menopause. Patients don't even know the symptoms of menopause. The person who was doing my makeup this morning, she's like, I just feel awful. I feel like an old person. I'm not sleeping. I'm not fun anymore. I can't drink. Joints are achy. And I said, welcome to You Need Hormone Therapy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I'm always teaching, no matter who I'm with, whether it's a cab driver, a hairstylist, I'm always teaching. But this idea of You have hormone receptors throughout your whole body. It is a whole body experience. So yes, there's hot flashes and night sweats. And by the way, hot flashes are not just a nuisance. That is a neurologic, vasculogenic probably event.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The worse your hot flashes, the worse your risk of cardiovascular issues and things like that. Joint pain is a huge one. I never thought as a urologist I would treat so much joint pain. Never in a million years did I think I cared about joint pain. And yet patients come in all the time and say, oh, my God, I don't get out of bed feeling old. I don't feel creaky.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Then you go at ovulate and that's in your mid cycle. And usually it's about 150. Let's say ish. Maybe it's 200, 300, whatever it is. Pregnancy, your level is 3000 or higher, right? It's very high. And so if you're in your normal reproductive cycle, you go from 50 to 150. So let's use the gas tank analogy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
My joints recover again after I exercise. Again, empty gas tank inflammation. I think hormones are nature's joint fluid, if you will. So almost like brake fluid. Go back to the car analogy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So it's really cool. So your eyes need lubrication. Your ears need wax. Your vagina needs lubrication. Your joints actually need lubrication. And so think of horny teenager. You've got oils, oily skin. So hormones create these oils, vaginal lubrication, oil for your skin. There are androgen receptors in your eyeballs, right, in these myobian glands. So I think of hormones like fluid.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So as you lose the hormones or the hormones go too high or too low, it dries everything out. And so you get joint pain, you get frozen shoulder, you get plantar fasciitis. And now it was recently published on by my colleague Vonda Wright, the musculoskeletal syndrome of menopause. This idea that so many women in their 40s and 50s, everything starts to break down.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's because the gas tank is empty and that inflammation increases. It's such a simple analogy. So what are the symptoms you've got? Musculoskeletal symptoms, sleep issues, mood issues, bleeding changes, obviously low libido, orgasm problems, arousal problems, pain with sex increases like crazy. I sent you a list here. What am I missing? You've got a list there.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's one of the most common symptoms. All women start going to doctors in their 40s. Like doctors, I know you're listening and you get so many people and every day you say, oh, it's probably hormonal, but you're not giving them the solution. You're just telling them it's not cancer. So the neurologists are seeing all these patients to rule out cognitive decline or all these other issues.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But really, it's that brain fog because your brain is filled with estrogen receptors. This is crazy research. OK, I don't know if you've had Lisa Moscone on, but here's this researcher from Cornell, neuroscience researcher, who says, hey, I want to study Alzheimer's. I want to do this. This is just in the last couple of years.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And she goes to her lab manager and says, OK, what's the assay for estradiol in the brain? I need to look at estradiol receptors in the brain. And the people at Cornell was like, that doesn't exist. She's like, what do you mean that doesn't exist? She's like, how can we not look at estrogen receptors in the brain?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So she gets Maria Shriver to give her a giant amount of money, who gives her a huge amount of money. So she now develops this assay. This is only within the last couple of years. She just published in Nature, very early findings. What would you expect? Your body is efficient. It's not going to do things it doesn't need to do.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the hypothesis was that as menopause gets later and later, the estrogen receptors in your brain are going to downregulate. Why have receptors around when there's no estrogen to feed the brain? What did she find? The exact opposite. That actually, even up to 65, she stopped looking past 65 because she's like, there's no way that's going to matter.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The increase in receptor density, the older you get, and it correlates to brain fog, correlates to all these symptoms.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You're at a quarter tank at 50, and you go to three quarters tank at 150, then down to a quarter tank. You can drive wherever you want to go during that time. What happens in perimenopause, and it is this chaos and erratic fluctuation where your body is just wanting more hormone than it has. Your brain, your FSH is telling your eggs to do more than they can. Sometimes they overshoot.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
To get every morsel.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And could you argue that weight gain in menopause is evolutionary so that you make more estrone or whatever, right? That then goes to the brain because it wants every morsel that it can get. So this idea of hormones matter for the brain deeply. This is very important. This is fascinating research, but you're going to see a lot of, again, think of a receptor.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
As perimenopause is happening, the receptors are full. Now they're empty. Then they're full. Now they're empty. Now they're half full. Now they're empty. This is why we see ADHD pop up in perimenopause. All these women are saying, I have now new diagnosed ADHD. It's real. Why?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Because your brain is having a panic attack because it's just trying to figure out some stability here, which is why actually in empty gas tanks, so in menopause, when you are totally empty, the brain fog gets better.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But if we just, all I'm saying is just add some estrogen to just keep the receptors happy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay, so this is my favorite topic in the history of topics because we used to call this problem, initially it was called senile vagina. That was the initial, yes, there was papers written on the senile vagina.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
An old vagina, I suppose, but then it got changed to vulvovaginal atrophy or atrophic vaginitis. That was the terminology that was used up until 24. Before that, it was senile vaginitis.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Check the history books. Very fascinating. So vulvovaginal atrophy was sort of the common name of this. Okay, as you get older, the vagina atrophies, it shrivels up, it shrinks up. Again, if a penis shriveled up at age 52, we'd probably have a vaccine sponsored by Pfizer. They created Viagra, they would create this vaccine.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What do you think, right? Tell me what you think.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This is the thing we just call the vulvovaginal atrophy. And we said, well, if you have pain with sex or a little vaginal dryness, here's some moisturizers. Here's some lubricants. Here you go. If you're really bothered, really bothered, you got to be really bothered. Then there's this thing called vaginal estrogen that we could give you. Now, here's the crazy part of this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's not just a little vaginal dryness. The vagina and the bladder need hormones. Babies don't have hormones, and that's why you see it's red. It's irritated. There are these small little labia minora. Diaper cream was invented because it looks so painful. They pee their diapers all the time. The genitals morph and change with hormones.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Puberty happens, and you have a change of the genital and urinary system. What happens is as you lose hormones, it goes in reverse. It changes the microbiome. The hormones keep the tissue acidic. It grows the healthy lactobacilli. The vagina is supposed to be acidic. It's supposed to be able to fight infection. And without proper hormones, you lose that ability to fight infection.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So now you are overflowing gas. I had a lady come in, her day one, her estrogen was 200, and her day 10, her estrogen was 900. So this is this wild fluctuation in perimenopause.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So you see urinary frequency, urinary urgency, vaginal dryness, increase in leakage, increase in urge incontinence, and recurrent urinary tract infections, which can and do kill people. We've known this since the 90s in the New England Journal of Medicine. Actually, this was on estriol. You could reduce the risk of urinary tract infections by well over 50%. We have known this all along.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. Correct. I think it's available in Europe. So the name got changed in 2014. 2014, a bunch of people got in a room and they said, you know what, this vulvovaginal atrophy thing, that's kind of a bad name because it doesn't describe what's really happening to people. So they changed the name to genitourinary syndrome of menopause, GSM.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now there was one urologist, my mentor was in the room, and they almost didn't put the word urinary in it. And he fought and he yelled and he screamed, this is the power of one person to be able to change the whole world. And they said, okay, we'll listen to you. We'll put the word urinary. in it. And I'm so glad they did because the urinary problems are the things that kill people.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
People are dying of urinary tract infection. In fact, a large amount of money goes to Medicare expenditures when it comes to urinary tract infections. And we published last year that if Medicare patients used vaginal estrogen, which is safe for everybody, and $13 a tube, we would save Medicare between $6 and $22 billion a year. Billion.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When you do a low-dose local vaginal estrogen or DHEA product, you can reduce your risk of urinary tract infections by more than half. They are safe to use if you've had a history of blood clots, breast cancer, whatever medical problem you can come at me, I can tell you that it's safe. It will not only help with lubrication, help with pain with sex, help with urinary frequency urgency leakage,
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
but it will reduce your risk of urinary tract infections by more than half. It's also inexpensive and covered by your insurance. If everybody in Medicare eligibility used vaginal estrogen, we would save Medicare between $6 and $22 billion a year. And in my opinion, that is a conservative estimate because of how many patients are getting urinary tract infections.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They're going to their doctor for cultures. They're in the ICU with sepsis. This is a huge economic morbid and mortality problem that we are dealing with and no one cares.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think we have a marketing problem. I truly believe this is a marketing problem.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's getting better. But again, they don't know how to write the prescriptions.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. If you can't get them, it's not over the counter. If you can't get the prescription or if you don't go to your doctor saying that you need it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We had an Instagram reel just yesterday that the patient said, my friend went to her doctor, said she was having pain with sex, asked for vaginal estrogen and her gynecologist said, and I quote, you need to think of other ways to change your relationship from now on. It's not in the cards for you.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Meaning you can't have sex anymore. You can't have sex anymore. And the fact is it's not about sex, it's about urinary tract infections.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
In her 60s.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Honestly, I don't know anymore. It's incredible. So we could argue Viagra. 1998, Viagra comes out. Viagra changed the world. Billions of dollars. What is Viagra? It is a PD-5 inhibitor. It relaxes smooth muscles of the penis, increased blood flow, gives you a rigid erection. So it helps with arousal for men, okay? If you take it microdose, low doses, it can also help with BPH or urinary problems.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We love Viagra. We love Cialis. Wish it was in the water. We should study it in women.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Oh, I'm going to talk about that. But I will argue we've had Viagra for women long before we've had Viagra for men. And we've known about it since the 1970s. And 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.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And they prevent urinary tract infections. Viagra doesn't do that. So you're talking about better than Viagra. It's inexpensive. Now, it didn't used to be. So when I got out of my training, a tube of Estrace was $500. Now, because of people like Mark Cuban and GoodRx, and I've talked to Mark Cuban on my DMs and Twitter, and he knows more about vaginal estrogen than 90% of doctors.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But this idea of it's not expensive. A tube of estrogen is $13.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. Yeah. They changed the game. Awesome. And so it's incredible. Oh my gosh, it's incredible. And he understands this. He literally understands the nuances of why vaginal estrogen is so important. I can't get doctors to do that. I think he's incredible. So we have a marketing problem. We have a product that is better than Viagra for women. It's been around longer than Viagra. It's inexpensive.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What are we missing? It's marketing. We're not telling the patients. We're not telling the doctors. And we have a box labeling that says this product causes stroke, heart attacks, blood clots, probable dementia, breast cancer, and needs to be taken with progesterone. Not one of those statements is true. Not one. Okay, so we went to the FDA and says, you got to remove the box. You're killing people.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And the FDA said, nah, mm-hmm. We're going to leave the box on. This is a nightmare. Can I just tell a very personal story? I promise it won't take long. My mother just died in November. We spent six months in the ICU in Houston, Texas. Six months, my mother, nobody should be in an ICU for six months. It was absolutely gut-wrenching, horrible time for me.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
My mother had been on vaginal estrogen because I want her to prevent UTIs for many, many years. You know, she's a 70-year-old woman, many years. So she gets into the hospital, has a transplant, has a catheter, and isn't doing well, is on ECMO and very sick for a very long time.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And I said to the doctors, I said, I know this isn't the most important thing in the world, but I'd like to restart her vaginal hormones because having a catheter, being in an ICU and being immunocompromised, my mother's risks of a urinary tract infection are incredibly high and a urinary tract infection is going to kill this woman. So I would like to restart her vaginal estrogen.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And because menopause medicine is a tiny little field in a tiny little corner, they looked at me like I was an insane person. I said, what do you mean? Your mother's very sick right now. I said, I know my mother's very sick right now. And this is one thing I can control. I sort of did a do you know who I am? Because I'm on the guidelines committee for GSM for the American Urologic Association.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So for the transplant team, I had to write up a whole S-bar of like, here's why it's important. Here's the research. Here's all the literature. Here's the citations. And they said, but it'll increase her risk of blood clots. I said, no, it won't. Vaginal hormones don't increase your risk of blood clots. It's like hydrocortisone cream compared to a solumedrol. Those are very different things.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And that video is so fantastic. We actually were talking about it before doing this podcast about that video. And I said, you know, if you asked most OBGYNs to draw the menstrual cycle, many of them wouldn't be able to do so. It's incredibly complicated. And it's so confusing. And we think our doctors know everything. And unfortunately, they don't.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So then they went to the ICU team. I said, no, we can't give this to her to increase her risk of blood clots. Had to convince them. Then the pharmacy, they finally got them to write the prescription. I had to teach them how to write the prescription. Pharmacy wouldn't dispense it. Why? It increases the risk of blood clots. It says so right on the box. So I had to call and yell, right?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I'm trying to run a practice in Washington, D.C. My brother and father are trying to advocate with me because they know they also follow me on social media. They know this is important. Finally, the pharmacy dispenses the tube of Estrace. There's no applicator. The nurses don't know how to give it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I had to show them and teach them how to give my mother, who is on ECMO and ultimately passed, not from a UTI, thank goodness, but had to show them how to dispense I had to do all this being one of the leading educators on this topic. What does everybody else do? And guess what? The teams changed every week. We had to do this every week and to teach them why this was important and how to do this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Vaginal hormones should not be gynecology. It should not be a small subset of menopause medicine. We could save Medicare between $6 and $22 billion a year if people understood this, if the box labeling weren't on there. I mean, it is so personal at this point, and yet it is horrible.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
maybe even not later in life. So we find that systemic hormones are not often enough to help with the genital and urinary symptoms. Most doctors don't know this. Again, what are you afraid of? You're not adding any systemic risk. It doesn't increase. If your estrogen level is 70 on your patch and you add a vaginal estrogen, her estrogen level is going to stay 70.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You're not going to get that systemic absorption, but you are going to reduce your UTI rate significantly.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We just published a study that DHEA does the same thing. It reduces the risk of UTIs by more than half.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So they've looked at a lot of oral, you probably know this data better than I do, oral DHEA, the data's all over the place because your adrenals are pumping out a lot of DHEA. But when you put DHEA vaginally, the idea is that your vaginal enzymes convert it into both estrogen and androgens.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so what happens is estrogen, you have your period, your lining of your uterus is shedding, your estrogen is kind of at its all time low.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And what's so fascinating is we know that the vagina, the vulvar vestibule, the clitoris, the bladder have androgen receptors. So us using just estrogen in this tissue may be missing the whole point. We do have patients that benefit from having an androgen in the tissue as well. And the only FDA approved product we have is Intrarosa, which is vaginal DHEA. Now, it's often hard to get for patients.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If I could get it for everybody, I would. It's fabulous because the tissue needs androgens. The data is very good.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So there is some data, not a lot, but there's data that shows someone with urgency, give them vaginal estrogen, switch them to DHEA. It'll help those people who still have urgency.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We published on this. So we just published in the Menopause Journal that it shows the same decreased risk of UTIs by more than half. So that was a very proud publication that we just put out. We use it frequently. What's nice about the product, it's a nightly product. It's DHEA and palm oil. So it's very moisturizing, very lubricating.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And my mentor, Erwin Goldstein, published that actually it also helps the tissue called the vulvar vestibule. Do you know what the vulvar vestibule is?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So I'm obsessed with homologues. Homologues are sort of this idea of, I'll give you an example. The penis and the clitoris are exactly the same thing. Yes, yes, sorry. No, no, no, that's okay. They're homologues of each other, right? The head of the penis and the head of the clitoris, homologues. So it's what part of the body in one is the same in the other.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the homologue of the scrotal skin is the labia majora. Okay. You're with me. The prepuce or the hood, the clitoris and the penis both have a prepuce or a hood to it. So there's a line that goes down a penis that goes down the penis and the scrotum. Do you remember what that's called? Median- Raph. Yeah. You got it. Raphay.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay. So the median raphay is the line that goes down the penis and the scrotum, straight line right in the middle. What's the homologue in the vulva? I just learned this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
No. No.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Close. Labia minora.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So it's skin. It's ectoderm. So it is skin and we're split open. So if you take the median RAFE and you split it, that's your labia minora, which is very hormone sensitive. I'm not on TikTok, but I am trending on TikTok because I talk about the labia minora shrinking and disappearing in menopause and the internet has broken because of it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Right. In this non-pregnancy state, you didn't make a baby, you're shedding the lining, your estrogen's about 50, let's say, to make it easy. Now it's starting to go up, up, up, up, up, and you're developing this follicle. So this egg is developing, and then the LH is sort of your brain's marker of, okay, it's time to ovulate.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the labia minora is very hormone sensitive tissue that we do not study and we know almost nothing about, but it resorbs in menopause. Inside the labia minora, so if we cut into the median raphe in a man, and we do this when we put in penile implants or we do urethral surgeries, we get to the male urethra. So Peter, your outside of your cheek is skin.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The inside of your cheek is different tissue. One's more sensitive, one's thicker. So the skin of the median raphe is very different than the skin of the tube of your urethra. You agree? For sure. So if you split open the labia minora, you get to the urethra. And that is the vulvar vestibule.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the tissue that surrounds the urethra in a woman that goes all the way around, and I will show you nerdy anatomical diagrams when we're done here because I need you to know this. That is the female urethra. It's called the vulvar vestibule. It is made up of endoderms.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So we think of the cervix as a transition point, but the most important transition point that affects sexual health in a woman is when you go from ectoderm of the labia minora to endoderm of the vulvar vestibule, and then past the hymen is mesoderm. It's fascinating anatomy. Why is this important? It's super compressed.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's so important because if you push with a Q-tip on the labia minora, they'll have no pain. If you push them on their vulvar vestibule, they'll say, that's my UTI. That's my interstitial cystitis. That's the pain that I have with sex. It is rich in hormone receptors.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This is why 50% of women go off their endocrine therapy for breast cancer because they have urinary symptoms, pelvic pain symptoms, and it is all sourced in a body part that no one taught you in medical school. And I did that on purpose because I knew you wouldn't know it. because no one is taught how to examine it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They put a speculum in and they bypass it completely and they are missing the problem. Back to the DHEA, this tissue has estrogen and testosterone receptors in it. So sometimes estrogen is not enough to help this vulvar vestibule tissue. And so DHEA, there's some data. There's one paper to suggest that DHEA is enough. And this is the one time that I will compound a product for a woman.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Otherwise, I use FDA-approved products in my practice. And I compound basically the amount of estrogen and estrogen vaginal topical cream, the 0.01%. And I will use a topical testosterone 0.1%. different than the 1% we talked about for libido, but a 0.1%. They rub it topically on this vulvar vestibule. You cure pain with sex. You help these UTI symptoms.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Interstitial cystitis goes away in so many patients. It's miraculous.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
0.01% estradiol. And we typically use a VersaBase or a methylcellulose base.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
No, but I would love to see that studied.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It can be usually a methylcellulose or a VersaBase. There's a base called Elage that a lot of people are using right now. Again, I am not a compounding junkie in any way. This is a miraculous compound that literally will, if you have a patient who's on vaginal estrogen, systemic estrogen, systemic testosterone. I said, Peter, I still have pain with sex. It still kind of hurts.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So that's when you pee on a stick and you're trying to check if you're ovulating, it's checking your LH levels. And so you're going to see this increase in LH that happens, again, everyone's a little bit different, but it happens kind of mid-cycle, day 10 to 14, somewhere along that, again, urologist, not gynecologist.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's always the vestibule.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Isn't it fun?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So we have this idea in menopause medicine called the timing hypothesis.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The window or the timing hypothesis. So the question of the timing hypothesis is what are you afraid of? What are we worried about? We're worried about blood clots. We don't want to hurt people. We're worried about cancer. We're worried about blood clots. We're worried about heart disease. But the question is, is does the hormone therapy that we use apply to the data that we have?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And I would argue it doesn't. And so there is a level of we don't know what we don't know. But even the timing hypothesis using PremPro, which was the medicine used in the WHI, is under question. So Susan Davis from Australia just wrote a big paper questioning the timing hypothesis and say, actually, when you look at the data really closely, doesn't really hold muster.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We shouldn't really be forcing people to say you cannot start hormone therapy after 60. So I think this is where shared decision-making really comes into play of what are we treating? Do you care about your bones? Do you care about your sexual health? Do you care about your mental health? And do you want to see if hormone therapy helps with these things?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now, hormone therapy is indicated for three reasons. Vasomotor symptoms, hot flashes, night sweats, that sort of thing. prevention of osteoporosis, which to me is a green light. So anyone should be offered hormone therapy because who wouldn't want to prevent osteoporosis? And the thing I just talked about a lot is the genitourinary syndrome of menopause.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So anybody of any age, and I'm talking even perimenopause and premenopause, vaginal estrogen or DHEA is safe and really helpful to prevent UTIs and should be used absolutely everywhere.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Throughout life.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so you get this LH surge, the egg pops out, and it is the shell of the egg that creates the progesterone surge. So you actually don't make any progesterone really in that first half of your cycle. And then after ovulation, we call the second half the luteal phase, which just means that's when progesterone is around. And so you get this surge of progesterone.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Definitely not. So that's really, there is no data to suggest stopping it. In fact, stopping it, all of your bone gains go away. They all go away quickly.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So keep them on. Again, this idea of if it's not broke, don't fix it. By taking a woman off of hormone therapy, you actually potentially could be disrupting any plaques that are there. You could be causing vasospasm. There are all these things that could happen. We really don't want to take women off their hormones. therapy unless there is a reason to.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And the only reason I honestly see is if a woman has an active cancer that you are going to target hormones as a target for your treatment of cancer. That's not to say the hormones cause the cancer, but we have a target sometimes because all body parts have hormone receptors and we have used hormones as a target for our breast cancer therapies and some other cancer therapies. Is that helpful?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Does that make sense?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So first, we take a long time at my clinic and we get to know each other. And we really try to dive into the data and say, what do we know? What do we not know? And I always tell people, you can't take hormone therapy because Rachel Rubin tells you to take hormone therapy. You have to do your own research, figure out what you're interested.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so I have a lot of colleagues who are talking about this. You had Avram Blooming on your show, and he has a great book called Estrogen Matters. He's an oncologist who's questioning a lot of this research.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We have amazing colleagues of mine like Corinne Mann, who is a gynecologist who had breast cancer as a young person in her 20s and now takes hormone therapy and talks a lot about hormone therapy and teaches courses on hormone therapy and breast cancer. So I am always learning. So I don't like fear. I don't like telling women they can't do things with their body.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I like understanding, well, what are we afraid of? So when it comes to the BRCA patients, if you do surgical menopause on someone and they don't have cancer and you do not give them back hormone therapy, you are trading one problem for another.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You may give them extra life from a breast cancer perspective, but you are shortening their life from a bone health and a cardiovascular disease perspective. That is very clear. So the other problem is the DCIS. If you are not going to give someone endocrine therapy of any kind and they're done, they have surgery, they're done, there is no reason why they can't take hormone therapy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And then when it comes to active breast cancer, there is a lot of emerging questioning in this patient population. And again, the question is, if you're allowed to get pregnant, are you allowed to take hormone therapy? And that's really the pushback that we give some people. And I think there's a lot of data that we need here, but we need to be asking these questions. I'm a urologist.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When I came out of my training, it was testosterone fuels prostate cancer. Now, 10 years later, it's you have prostate cancer. Sure, we can give you testosterone. No problem. If you have metastatic disease, we target testosterone. So we're going to use castration level androgen blockers. But that doesn't mean if you have localized disease that you can't have testosterone therapy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When there is no fertilization, that shell of the egg evaporates and then you lose your progesterone. And it is that withdrawal of progesterone that causes the uterine lining to shed. Now, again, this is very confusing for people because hormones through that time, your progesterone goes from very, very low to after you ovulate, very, very high. And it's that cycle every month.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So we think of testosterone and prostate cancer as a saturation model concept. And I actually think we need to be using that model potentially when it comes to breast cancer and have more logic and understanding and less fear. It's marketing. All prostate cancer...
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
is testosterone-sensitive prostate cancer, but we don't cut off testicles for the fear that an abnormal cell will happen in a prostate. A lot of breast cancer is estrogen-receptive breast cancer, not all of it, right? But some of it is. That doesn't mean estrogen causes cancer.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And this is, again, where that patriarchal divide happens is we're willing to take those risks and focus on quality of life when it comes to men's health. We castrate women with the mere thought that they may develop an abnormal cell in their body and completely ignore their quality of life and all of those things that go with it. And women are more than breast tissue.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They are so much more than their cancer risk. And we have to understand and actually have these reasonable conversations with with women. And what I say is your oncologist is not in charge of you. They give you advice. It's like a pit crew. Let's go back to our car model. You have a pit crew, but you get to decide who's on your pit crew and who fits into your pit crew.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But it can't be just one doctor. You may need someone to talk about your sexual health. You may need someone to talk about your menopause hormones. You may need a bone doctor. You may need a heart doctor. So you need to collect your pit crew. But when one doctor says, no, you can't do this with your body, I don't like that terminal. I don't think it's fair anymore.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And when you give women information about how their bodies work, they make great decisions for themselves. They can look at the menu and say, listen, I'm most worried about Alzheimer's and I've looked at the data and this is what I choose to do. Or, hey, I'm more worried about osteoporosis. Listen, my grandma broke a bunch of ribs. She had Alzheimer's and osteoporosis.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And my grandpa hugged her and she broke a bunch of ribs. That's not how I want to age. So what do I care about? I don't want to get osteoporosis. I don't want to get dementia. And I've seen all the literature. Hormone therapy sounds pretty good to me. And that's really the key. I think there's a lot of people on social media, maybe negative about hormone therapy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But if you look, they are on hormone therapy themselves. They will say they have an estrogen patch on.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This idea that we are overselling HRT, that not every woman needs HRT. And I'm not suggesting every woman needs HRT, but I want every woman to be offered the menu. I want them to know what they are, just like I want people to know how to exercise and lift weights and eat healthy. Here's the menu. If you choose to smoke and drink and do drugs, that is your choice.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now, estrogen, again, goes from 50 to 150, back down to 50. That's what the book says. I don't know about you, but my patients are not all on the book.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But I want you to know that the menu exists.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There's danger on both sides. There's danger going to the doctor for 10 minutes and saying, oh, that's not safe. You don't want to do this. And there's dangers of going to the very expensive pellet clinic that is going to overdose you and charge you lots and lots of money. So I like being somewhere in the middle and getting a few opinions here.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So this is where opinions can be a bunch of people on Instagram. Don't just follow one people. Follow a bunch of people. If you like books, there's tons of books now on menopause.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You've got Mary Claire Haver has the most popular book called The New Menopause. Heather Hirsch has a great book called Pick Your Menopause Type. There's been Hot and Bothered. A journalist wrote a great book on perimenopause, Jancy Dunn. Tamzin Fadal just wrote a book about menopause, who's also a reporter. Estrogen Matters is a great book, a really great book.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There's a lot of books now, thank goodness. There's one called The Menopause Manifesto. There's great books on menopause. There's also podcasts now. There's great podcasts out there. Oprah just did a special. There's documentaries on PBS now. So menopause is having a movement. So you can't have this excuse anymore of, oh, my doctor doesn't do this. Go find a different doctor.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There are telemedicine companies.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So menopause.org is the Menopause Society website. That doesn't guarantee you have someone who knows everything. But menopause.org means somebody took a test and put some effort into saying, I care about menopause. I'm on that website. But ISWISH, I-S-S-W-S-H dot org is the Women's Sexual Health Society. So people who we care about menopause and sexual health.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So that's a great place to find a provider. So those are two websites that can help you find someone. Again, you have to advocate for yourself because no one will do that other than you. And so I think the more you educate yourself, the more you can find the right people in your pit crew who are going to fill that gas tank and get you to where you want to go.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I agree completely. And so we're super interested in this. We care about how people are feeling. I may say this a lot during our conversation is there's the book answer, there's the Instagram answer, and then my answer is somewhere in the middle is how we sort of talk about it and understand it. Again, I think the numbers are helpful for people to see. When you're pregnant, your estrogen is 3,000.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think this is a problem. When your doctor says, no, you can't have anything, that's suspect. If your doctor says you can only have this really expensive product that has to be inserted into your butt four times a year and you have to pay me thousands of dollars, that's extremely suspect.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If they say you have to pay lots of money for this special compounded product that's safer and more effective, I call red flag on that situation. If you have to give very expensive saliva testing labs and they're making you pay a lot of money, very suspect. Again, that doesn't mean you can't do it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If it's working for you and you're happy, you have body autonomy, you do what you want, but know that there's red flags there. I think the pellet industry, I have a big problem. We have an FDA-approved pellet for men. It can be FDA approved. I'm not upset with a pellet as a concept. If the pellet companies cared about women, do the studies, go through the FDA, show me it's safe.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's billion dollar industry. If you believe that it's the greatest thing in the world, Show me so that I can start using it because the FDA is a pretty good compounding pharmacy. So do the work. I have my beef with the FDA. Hello, you need to take that box labeling off estrogen products, especially vaginal estrogen.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But if the pellet companies deeply cared about women, which they say they do, do the work. Everyone takes advantage of women. All the supplement companies, they take advantage by promising these things to women, but they don't do the work of science. So that's what I ask is just do the work.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Can I say one thing real quick? I'm also a men's health doctor and I lecture my urology colleagues and I say, and you talk about longevity and here are the things you can do for longevity. I think you're missing one point. And that is that men who are divorced, single or widowed have horrible health outcomes. Horrible. Whether you look at mental health, prostate cancer, cancer outcomes, horrible.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They die sooner. So if you want longevity, if you want to keep living, you have to keep people partnered. And when do people get divorced? Between 40 and 60. That is the age of perimenopause and menopause. Menopause is killing men. It is killing men because it changes their marriages and it leads to divorce, which leads to death.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When you're regularly ovulating, it's 50 to 150. Perimenopause, it could be zero. It could be a thousand and down to zero in two seconds flat.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I give this lecture of if men's health doctors, if doctors truly cared about keeping men alive, they would do menopause medicine because that is one of the most important ways to keep men alive. So that's my other argument for you to focus on this and really make change here. And I'm just can't thank you enough for this platform because it is everybody's problem.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Thanks for having me.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think it has to do with the fact that you have a limited number of eggs. You're sort of getting to that end of your bucket of eggs that you're born with. That's, again, controversial on the internet. So your body is really trying to do what it has always done, and it's just having trouble. It's having trouble recruiting the egg, ovulating. You don't ovulate every time.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Sometimes you ovulate twice, push out two eggs in this perimenopause cycle. So we can sometimes see really high elevations, which can come with symptoms. And that's the challenge of perimenopause is sometimes you have symptoms because you're too low. Sometimes you have symptoms because you're too high. And sometimes it's that fluctuation. Like, again, we'll go to the car model.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You're driving 100 miles an hour on the highway and you go to empty gas tank immediately. That is not good for a car. That is inflammation. That is irritation. That is a lot of perimenopause symptoms.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I knew you would like this analogy.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think it's a really important question, and we see this clinically all the time. If you give somebody, say, micronized progesterone or a synthetic progestin, say, in birth control, you will see a wide variety of reactions to these different medications.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so I would say it has to probably do with the GABA receptor in the metabolites of progesterone and how the receptors in the brain use these molecules. And so I think we just don't know enough. You know, I tell my patients all the time, I wish... Oh my gosh, we have so much work to do in women's health. We have so much research we need done.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This is why I come on this platform, not because I want to be on this platform, but I need smart people to be listening to this, to ask the research questions and to do this research. Because clinically, we see this all the time. I will... put up that menstrual cycle with my patients and say, when do you start to have symptoms? Are you having symptoms when your estrogen is falling?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Are you having symptoms when your progesterone is falling? And can we hack this system to help you feel better? And how are you going to respond to it? Because when we give someone micronized progesterone, I would say a third of the patients love it and guzzle it like it's candy. And they're the happiest people in the world. Helps their sleep, reduces anxiety. Oh, my God. Changes their life.