How to Take Care of your Clitoris....The Right Way! Ft. Dr. Rachel Rubin

0:00 Every woman over the age of 50 goes to an empty tank.

0:03 It's fact.

0:03 It's castration.

0:04 It is no longer hormones.

0:06 All I can guarantee you ahead is shit's about to get weird, right?

0:09 And I think there's this whole timeline of people in their late 30s,

0:13 40s, and 50s where you really start to NLM not feeling like myself.

0:18 I remember being told, "Don't go near the clitoris cuz you

0:22 don't want to make your patient uncomfortable." Reena, you and I are urologists.

0:26 Can you imagine us being told don't touch the penis?

0:29 Sex is supposed to be fun.

0:30 It's supposed to be joyful.

0:31 It's supposed to be adult playtime and and playful.

0:34 And so if you're not talking about it, trying new things,

0:37 it's going to get a little stale and a little bit, you know, maybe lonely.

0:43 Did you know there's a part of female

0:44 anatomy that's only job is to provide pleasure?

0:47 And most doctors never even examine it.

0:50 In fact, most women have never even seen their own anatomy with a mirror.

0:54 I'm Dr.

0:55 Reina Malik, urologist and pelvic surgeon,

0:57 and welcome back to the Reena Malik MD podcast.

1:00 Your trusted source for leveling up your health,

1:02 relationships, and sex lives with evidence-based tools.

1:05 Today, I'm joined by my dear friend and colleague, Dr.

1:08 Rachel Rubin, the urologist and sexual medicine specialist

1:11 who is redefining the standards of women's healthcare.

1:14 She challenges outdated textbooks and has created global education platforms.

1:18 She is the leading voice for hormonal and sexual

1:21 health and is literally changing the future of medicine.

1:24 In this conversation, we are covering so many things.

1:26 We're talking about the clitoris and why even anatomy

1:30 textbooks don't show the full structure of the clitoris,

1:33 clitoreral adhesions that affect up to one in five women,

1:37 the ulvar vestibial, which is a hidden cause of sexual pain,

1:41 how birth control pills affect sexual function,

1:44 and what's actually happening to your genitals during menopause.

1:47 and we talk about vaginal hormones and why only 9%

1:51 of patients receive this treatment even though it can be lifechanging.

1:54 This is a conversation about bodies pleasure

1:57 and medical education that should have happened decades ago.

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2:33 Dr.

2:33 Rachel Rubin, I'm so happy to have you here.

2:36 I'm so glad we finally got to do this.

2:38 You have been a wonderful friend and even though we're contemporaries,

2:42 I found you to be like a mentor at times and someone I can come

2:46 to when I have questions and it's just been such a great pleasure knowing you.

2:50 It's such a joy to be contemporaries because what I learned about

2:54 mentorship is that I have so many mentors now that are way younger

2:58 than me that show me how to do the buttons and help me

3:00 with so many things and then obviously so many people older than me.

3:04 But it's really this wonderful community where we can learn from each other.

3:07 Yeah.

3:08 And you know, before this, we were talking about how we need

3:11 to be looking at the couple instead of just the individual man or woman.

3:16 And I think it's so interesting because a lot of my audience is men,

3:19 but they do genuinely care about their female

3:22 partners and making them happy and giving them pleasure.

3:24 Tell us about your experience in taking care of couples.

3:27 Yeah, I think it's so important.

3:29 And we were talking at breakfast this morning

3:31 about how because we're actually friends in real life.

3:33 Um, but we were talking about how challenging this is because the way

3:37 medicine is set up right now is the boys go to the boy

3:40 doctor and the girls go to the girl doctor and they never

3:44 talk to each other or even understand what's happening with the other one.

3:48 And we minimize biology here and there is so much biology here that can

3:53 happen to everybody and it evolves over

3:56 your lifespan and we don't talk about it.

3:58 And so, um, then there's the whole psychosocial aspect, which is huge,

4:02 and how you approach this, how you talk about it, how you evolve this intimacy.

4:07 And there really aren't a lot of doctors to have those conversations.

4:11 And so, we talked about that there's

4:12 like 27 fellowships for men's sexual health.

4:16 There are now two fellowships um focused on women's sexual health,

4:21 but they don't do both.

4:23 Actually, my fellowship that I did with Irwin Goldstein,

4:26 who you had on the show, it's the only fellowship in the country

4:28 that even acknowledges sort of the couple, right?

4:31 And I can't tell you how much easier my job is

4:34 when I can really work with both sides of the couple.

4:38 Yeah.

4:38 And the issues are similar but different, right?

4:41 like the the the self-conscious, the thoughts, the the stressors are similar,

4:46 but they're often dealing with very different physiology and very

4:50 different issues physiologically that they don't even know what's going on.

4:53 They just feel like something's wrong with them.

4:55 And I find I can use things from my toolbox

4:58 for each one to actually help with the other one.

5:01 And when you give people sort of a language about their bodies,

5:05 their anatomy, how their anatomy works, and you can like share it with them,

5:09 it it kind of opens their eyes of, "Oh my gosh." And what I find

5:13 is it's easier to talk about sex when

5:16 you talk about like it's high blood pressure,

5:17 diabetes, or like, "Hey honey, I'm having a surgery." You know,

5:21 it's so much easier to talk about the biology

5:23 than it is the feelings and the intimacy.

5:25 And so sometimes we use the biology as a way

5:27 to get to the feelings and the intimacy.

5:30 Absolutely.

5:30 Yeah.

5:30 Absolutely.

5:31 So, let's talk about some of the the anatomy.

5:34 Let's talk about the clitoris.

5:35 As you've mentioned many times, and I have,

5:37 it is the only organ in the body that's solely there for pleasure,

5:41 but it's largely ignored.

5:43 So, what do you wish people knew about the clitoris?

5:46 Oh, I wish so much.

5:47 Right.

5:47 So, when we trained, um,

5:49 our anatomy textbooks don't show the full entire clitoris.

5:53 Right.

5:54 It is what we think of as if you follow the labia manora up those inner wings

5:59 then you get to the hood of the clitoris you pull that back you'll see the head

6:02 of the clitoris just like the head of the penis that is the tip of the iceberg

6:06 and so there is a shaft of the clitoris

6:07 and there are these giant legs of a clitoris

6:10 that go all the way down to your butt bones just like a penis sort of splits

6:13 into two and goes all the way down

6:14 to your butt bones and most people don't know this most

6:17 doctors don't know this because our anatomy textbooks

6:20 really didn't go into this and no one taught

6:22 us the clitoreral exam was not a part

6:24 of a routine exam when you're taught in med school.

6:26 In fact, I remember being told,

6:28 "Don't go near the clitoris because you

6:29 don't want to make your patient uncomfortable." Reena, you and I are urologists.

6:34 Can you imagine us being told, "Don't touch the penis.

6:37 You may make your patient uncomfortable." It's wild, right?

6:40 And so, people don't understand the anatomy.

6:43 And then there's this thought that pleasure comes from vaginal penetration,

6:47 which for most people is not the case.

6:50 And so it's when you understand that you realize that you're

6:53 you're quite normal in the way that you experience pleasure.

6:56 Absolutely.

6:57 And you were the person who taught me about clitoreral adhesions.

7:00 So just like men have foreskin and you pull it back and it can get infected,

7:06 inflamed, stuck, you can get smegma, women can have the same thing happen.

7:11 Yeah.

7:11 So let's tell talk about this.

7:12 It's so wild.

7:14 Okay.

7:15 So um about we did research in 2017 where we looked at thousands

7:19 of pictures of clitorises and about 22% of them had some degree of adhesions.

7:25 Now this isn't cancer, this isn't heart disease.

7:27 Uh it's literally the hood of the clitoris

7:30 gets stuck to the head of the clitoris.

7:32 I sort of think of it like if you wake

7:34 up in the morning and your eye is crusted close.

7:37 You know, you're like you don't go to the emergency room,

7:39 you just pick out the eye crusties and open your eye.

7:41 But if you think you can't see, that's a horrible thing.

7:43 But it's not that serious.

7:44 It's not.

7:45 And that's what happens to the clitoris.

7:46 It gets stuck together.

7:47 And then we found we actually asked

7:49 people what happens when you unstick it together.

7:51 We do a very a simple procedure in the office

7:54 where we separate the hood from the head.

7:56 It's not cutting.

7:57 We're not we're not doing surgery.

7:59 And 60 to 70% of people said their orgasms improved,

8:02 their arousal improved, their satisfaction improved.

8:05 Six women who had never had an orgasm before were able to after this procedure,

8:08 which was incredible.

8:10 And my colleagues have since published even more on it

8:13 and and replicating that data which is always very cool when that happens.

8:16 And so the challenge is is that no one's ever examined your clitoris.

8:22 Absolutely.

8:23 Ever.

8:24 Yeah.

8:23 And so we became very famous from this fact that we just give people

8:27 a mirror in the exam room and we're say this is your labia majora.

8:30 This is your labia minora.

8:32 This is your clitoris.

8:33 This is your cleral hood.

8:34 A and and it got a it got so

8:36 much press because that's apparently novel medicine in 2026.

8:40 You know, it's so funny.

8:41 I wrote about that in my book.

8:42 I said, you know, my dear friend Dr.

8:44 Rachel Rubin got famous from talking about

8:46 giving women a mirror in the exam room.

8:48 And I was like, if I did that for men, I'd be told I was crazy.

8:52 Like literally, if I was like, "Here's your penis.

8:53 Here's a mirror to look at it." People

8:55 would literally think I'm I've gone nuts, right?

8:58 And it's it's insane to me that that is like really I mean it's it's

9:01 it's a speaks to how far society

9:05 is from like making women's anatomy be normalized.

9:09 Yeah.

9:09 And it's so hidden from us, right?

9:11 Like men, they pull their pants down, they see everything.

9:14 You they see every wrinkle, every vein,

9:15 and if it changes, they're going to call us, right?

9:18 They see everything.

9:19 They're used to looking at their scrotum

9:21 and their testicles and all of this thing.

9:22 It's all out in the open.

9:24 And women there is this gymnastics that has to be done.

9:28 You can't really see down there unless you're looking and you get

9:31 a mirror and you're you're sort of so you don't always know what's happening.

9:34 And this is a dynamic part of the body.

9:36 It changes it.

9:37 A baby's genitals don't look like a grown-up's genitals.

9:40 And then when you go through hormonal changes

9:42 or shifts like in menopause, they change again.

9:45 But we've been hiding that from women.

9:48 Not on purpose.

9:48 It's just that we forgot to tell them which is a little bit frustrating.

9:52 You know the when I I actually did

9:54 a cleral adhesionis which is the name of that procedure

9:57 that we do for women with cleral adhesions

9:58 on a a young woman with persistent genital arousal syndrome.

10:02 So she had for those who are listening basically condition where she

10:06 always felt like she was aroused and would and it would be uncomfortable.

10:10 So it's not actually like a lovely thing.

10:12 It's actually very very uncomfortable very distressing and pe

10:16 patients get so distressed that some become suicidal.

10:18 It's like a very serious condition.

10:20 So she came to me, we did an exam,

10:22 we saw clitoral adhesions, I lice the clitoral adhesions and she got better.

10:26 It's amazing.

10:26 It's amazing.

10:27 So it's a really important evaluation.

10:29 So any woman who's listening, please look at your genitalia.

10:33 We're actually presenting a case at the conference

10:35 that I'm here for, which is why I'm in California,

10:37 of a young child uh from another country who had horrible,

10:42 horrible pain and irritation in that area of her body.

10:45 And she went to every doctor they could find in their country.

10:49 and no one could sort of figure out.

10:51 I don't even know if anyone examined her.

10:52 The notes just kept saying she needed cognitive behavioral therapy.

10:56 This was a young child and uh the parents because they had seen

11:00 our research brought her to our clinic and she had clitorol uh adhesions.

11:05 We brought her to the operating room because we

11:06 didn't want to do anything while she was awake.

11:08 We usually do it in the office and it was gone.

11:11 Like it literally she's she's better like and this was

11:14 to the point of tears every night at bedtime.

11:17 she was missing school.

11:18 She was always, you know,

11:20 like grabbing at that area when a simple

11:22 exam and a simple procedure sort of cured it.

11:25 And so, and that she was already being told

11:28 at such a young age that she needed cognitive behavioral therapy.

11:31 Like, you just can't make this stuff up.

11:33 Terrible.

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12:32 You also said the organs change during menopause and the genital organs.

12:37 And you actually also went viral for talking

12:39 about what happened to the labia during menopause.

12:41 I this was a funny one.

12:43 Um so it is scientific fact that labia

12:48 minora these little inner wings people call them lips.

12:51 I actually don't like that term.

12:52 It gives me the heebie-jebies.

12:54 So I like wings.

12:54 I always thought wings was a cool ter term.

12:57 So these these wings like babies they're very small.

13:01 They're very thin.

13:02 They're very very minimal in size.

13:04 And then puberty happens and they grow.

13:06 They get fuller.

13:07 In fact, many times they'll go all the way down to the sort

13:10 of bottom of the opening of like a full uh you know,

13:13 they fully look like wings.

13:14 Now, different people have different shapes and sizes.

13:17 And we really haven't done a good

13:18 job characterizing why they change size and shape.

13:22 Uh they are clearly hormone sensitive,

13:25 but we really don't have much research out

13:27 there about what hormones are driving these changes,

13:30 but we know that with menopause, they start to shrink or resorb or disappear.

13:36 Now, they don't always disappear completely, though they can.

13:39 And I I just like made a video about this and the internet broke.

13:43 I went so viral on Tik Tok, they made all these like joke videos about it.

13:48 I'm not on Tik Tok.

13:49 I was getting all of these things like you have millions of views.

13:52 I was in clinic and um within like one day my elementary school had

13:57 commented on the post and Kim Kardashian had texted someone to ask me about it.

14:03 Like was like, "Is that true?" And the person was like,

14:05 "If Rachel says it's true, it's true." So,

14:08 it just went so viral and to the point where other people started talking about

14:11 it and then they went viral sort of talking about it, which is so great.

14:14 I also had people telling me they that I should

14:16 lose my medical license because I'm clearly spreading fake news.

14:21 And it was like, "No, no,

14:22 like this is like an anatomical medical fact that this happens

14:25 and you're just there's so much anger about it because it's so no

14:30 one told you that this could happen and we don't talk to women

14:32 about it." And I think the women are very upset about that.

14:35 Yeah, absolutely.

14:36 And it's it's crazy, right?

14:37 Because people spend money on genital uh surgeries to change

14:42 the shape of their labia to look more like they're not there.

14:46 And that's what's so challenging is that again,

14:49 so much pornography depicts very small labia.

14:52 And part of that is probably because a lot of these uh uh actresses,

14:57 a lot of these uh a lot of these performers are

15:00 on birth control pills which probably changes the size of their labia.

15:03 Uh also people do have surgery and things like that.

15:06 But like big labia the big are hormonally healthy probably.

15:11 And so we don't do enough of teaching young people that actually

15:15 this is a sign of good hormones and good hormonal status.

15:18 There's a lot of nerve endings.

15:19 There's a lot of arousal tissue underneath.

15:22 And so rushing to a surgery,

15:23 we've seen a lot of unhappy people because surgeries can sort

15:27 of hurt nerve endings which can affect sexual health for some people.

15:30 Absolutely.

15:30 And and I will say that I think that performers self- select, right?

15:34 Because the performers that do well, you can visualize things better, right?

15:38 They act better when the laby are not in the way.

15:41 And so probably one they get more attention and two they self- select because

15:45 if you want to be in that field of of work then you need

15:49 to be able to see what's happening for the audience right so I think

15:52 that's probably part of it it's really

15:54 crazy the things that we're not taught about

15:56 our own bodies and and I talk about this a lot but I really

15:59 think sex ed in this school and you actually go back to your high school

16:02 is it and talk about sex at every year and there's just so many things

16:06 that we were not taught and and we just like are expected to learn somehow.

16:12 Well, I think it's so interesting, right?

16:14 Because we're not when are we supposed

16:16 to learn and how are we supposed to learn?

16:18 Because you don't really want to hear about

16:19 this from your mom and your teachers don't really,

16:22 you know, they can tell you some basic stuff,

16:24 but like where do we get this education?

16:27 Where did you get this?

16:28 Like we don't get in medical school.

16:30 And so this is where doctors become really fumbly and not

16:32 that good because they weren't taught how to talk about sex.

16:35 They didn't learn it themselves.

16:36 They spent most of their 20s in school.

16:38 So they weren't having fun.

16:40 most of us uh and you know and and so it's so challenging.

16:45 Every year I go back to my high school and every year I expected

16:48 not to be invited back because I I they do not give me any

16:52 guardrails or any rules and I went to a small private school and every

16:56 year I put up a big slide uh with my cell phone number on it.

17:00 Actually, I've been doing WhatsApp recently and all

17:03 the students can start texting me questions and it's

17:06 so fun because they they get really um they try to gross me out and they

17:11 try to like say ridiculous things and then

17:13 they realize that I'm actually going to answer

17:14 their questions and that I they can't make me blush and I don't skip a beat.

17:18 And it was it's and then I teach them about anatomy.

17:21 I teach them how the body works and then I'll

17:22 stop every once in a while and I'll answer their questions.

17:25 And it's such a fascinating thing because

17:28 there are kids who are doing stuff like

17:30 a lot of it's usually the seniors that we're

17:32 talking and then there's ones who are just,

17:35 you know, like sort of like can't believe

17:37 that we're having these conversations and it's wild.

17:39 And every year my actually the same principal who was my principal,

17:44 she'll be in the back of the room and she'll come up.

17:45 She'll be like, I learned a few things this year.

17:47 It's like mortifying.

17:48 It's hilarious.

17:49 What is What is one of the most surprising things that you got asked?

17:53 They ask a lot about anal sex.

17:55 They have tons of anal sex questions.

17:57 Interesting.

17:57 Um tons of questions about um how to get,

18:02 you know, a lot of pregnancy questions, a lot of safety questions, you know,

18:05 they they have a lot of curiosity about their each other's bodies.

18:09 And I think that's really interesting of like, well, you know,

18:12 how can I get my girl how can I get my boyfriend to know how I orgasm?

18:17 Well, you need to learn how to orgasm to teach your boyfriend how to orgasm,

18:21 you know, and I bring in a lot of models.

18:22 I bring in a lot of, you know, showand tell of like here's what it looks like.

18:26 Um, you know, I think it's we don't we don't talk about basics.

18:29 Like we don't teach boys how to masturbate or like what they should be doing

18:33 and and there's a lot of injuries

18:35 that can happen and and every year the question

18:37 I always think I should write a whole book about all the questions that I

18:40 get asked cuz and every once in a while I'll get texts from these kids

18:43 you know many months or years later of like hey you taught me sex

18:47 ed I got into this situation what should I do and and you know one

18:51 year I remember three different women came up to me and said I have pain

18:55 with tampons I thought I was normal but you're telling me that it's not normal.

18:59 normal.

19:00 And that was really cool because we got to get them, you know,

19:02 potentially to help sooner uh than they normally

19:05 would have gotten help cuz it's you should, you know, things shouldn't hurt.

19:08 There shouldn't be pain.

19:10 That's so amazing.

19:10 I wonder if you actually like studied this in a empirical way and looked

19:14 at like their outcomes of pleasure and sat

19:16 relationship satisfaction like years down the line, I bet you they'd be higher.

19:21 And it's interesting because it's it's sort of like you give

19:23 them the per like they sort of get shocked of like,

19:26 oh, like it's okay to talk about this.

19:28 And I think, you know, they've already had sex.

19:30 This is more just like ask the sex doctor anything.

19:33 And so I don't go into all of the doom and gloom and scare tactics.

19:37 I'm there to talk about pleasure and fun and joy and con,

19:41 you know, they they've done lots with consent.

19:42 They've done all this stuff, but really talking to them about like,

19:45 but like you deserve pleasure and here's how it happens

19:47 and know your body and if you know your body,

19:49 then you can advocate for it and you can talk about it.

19:52 And it's just wild, right?

19:53 you see these kids that are they can't even talk to each other and yet they are

19:57 touching each other's bodies in ways that are

19:59 so intimate so so personal um but they don't

20:02 have the language and so when you can work and I love that we do it all

20:06 together so the boys and the girls everyone's together

20:08 because then they have that shared language of like

20:10 we should be able to talk about periods

20:11 we should be able to talk about masturbation we

20:12 should be able to talk about orgasm and you should use the words of like what it

20:16 is you like and if you don't know

20:17 what you like you should probably find out because

20:19 how are you going to tell a partner you

20:20 know and expect them to know what you like yeah they can't read your mind.

20:24 It's this fascinating thing, right?

20:26 And it's wild.

20:26 Like I find with maybe you think this too,

20:28 like with my patients, the young ones who have sex problems,

20:32 by the way, everyone will have a sex problem at some point in their life.

20:35 Like that's inevitable.

20:36 And so I actually feel really bad for my older patients who

20:41 start developing problems in their 70s and they have no language around it.

20:48 Like I and my younger patients,

20:50 even though it's terrible that they have problems, they learn language.

20:53 They they actually fig they they learn how to communicate.

20:56 And I think they're better at sex ultimately than these other people who

20:59 are just kind of winging it in this silent dance for a while.

21:03 Yeah.

21:03 Yeah.

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22:31 You know, you brought up a good point

22:32 is that boys don't get taught how to masturbate.

22:35 And I think that really sets them up for a huge problem, right?

22:38 They're they are learning how to masturbate on their own,

22:40 which could be good or bad, whatever, but usually they're rushing through it.

22:44 They're hiding it from their their parents.

22:46 They're doing it in the shower, people, you know,

22:48 and and they feel shame around it, right?

22:50 And they they're learning to rush through this act of pleasure, right?

22:54 And I think that sets them up for a whole host of issues down the line.

22:57 Well, and also again,

22:58 who do you talk to if you have questions or problems or issues, right?

23:03 The pediatrician doesn't really get taught how to counsel about this.

23:06 The primary care doc, it's not their expertise.

23:09 Like my dream, I have so many dreams,

23:11 but one of my dreams is to have a clinic where you go

23:15 every couple of years for like just like you go to a wellchild visit,

23:19 you go for like an age appropriate sexual

23:22 health visit where maybe you start just with anatomy.

23:26 Then maybe it gets to questions about consent and masturbation.

23:30 Like it you just form this relationship where you realize

23:33 there is a place to go when I have questions.

23:35 So if something goes wrong, it's not, oh,

23:37 I have to search on the internet secretly late at night and no

23:40 one knows and then you end up on some shady, you know, thing.

23:44 It's, hey mom, can I go see the, you know, can I go to this clinic?

23:47 or you know how to kind of I just think it would be gosh this world

23:50 would be such a different place right if we had access to like good information.

23:57 Absolutely.

23:57 100%.

23:58 I mean, I think that I I know that you probably do this, too,

24:00 but I talk to my kids about sex

24:02 and about masturbation and about pornography and, you know,

24:05 try to leave the door open so they can ask me questions all the time.

24:09 And um my son is starting to read, you know, older books and he'll be like,

24:12 "Mom, what's the clitoris?" or like, you know, and and we talk about it, right?

24:16 Because I think it's so important.

24:17 And I do feel like even if we don't have that yet, right?

24:21 We don't have that sort of like come to this clinic and learn about sex.

24:24 The parents can learn and start learning how

24:26 to talk to their kids because guess what?

24:28 You're with them all the time.

24:29 And if they feel comfortable talking to you, that's amazing.

24:32 You should have my friend Carrie Le on the show.

24:34 She is this amazing doctor in Detroit who does a lot of um sexed for, you know,

24:40 she has these programs where they do sexed and there's a whole curriculum.

24:43 And she's taught me a couple things that I love.

24:45 You know, one is don't call them private parts.

24:48 She's like call them personal parts.

24:49 And I just think that's beautiful, right?

24:50 this idea they're not private, they're personal to you.

24:53 And when you have something that's personal,

24:55 you share it with the people you want to share it with, but they're, you know,

24:58 and the other thing that she said which I think is so beautiful is she says,

25:01 you know, talking to your kids about

25:03 sex should not be one 30 minute conversation.

25:06 It should be 31 minute conversations.

25:08 It should be something that is just talked about all of the time.

25:12 You can start at the zoo and talk about how elephants procreate.

25:14 who can, you know, watch TV shows and have these little moments of like,

25:18 you know, explaining interactions.

25:20 Cars are great places because you're not looking

25:22 at each other and you can have these conversations.

25:24 And I just think again,

25:25 the more we aren't afraid of it cuz they the kids are like dogs.

25:29 They smell fear, right?

25:30 They smell awkward.

25:32 They smell fear.

25:32 They know when you're uncomfortable with something.

25:35 And if we shut it down and we show, you know,

25:37 I think one of the things that makes us good

25:39 urologists is we show up confident and competent in these topics.

25:43 And so we talk about these things again like it's, you know,

25:47 I don't know, somebody else's high blood pressure, high blood pressure, right?

25:49 Like we talk about it very easily and I find that's

25:52 what makes these patients so comfortable talking to us about it, right?

25:55 Because we don't flinch.

25:56 If we flinched, they probably it would probably be a different story.

25:59 Well, maybe you and I don't flinch,

26:00 but I'm certain there are people who do flinch,

26:03 which is unfortunate, but hopefully we're changing that a little bit.

26:06 Let's talk about sex.

26:07 What are the top five things you think people need to know to have good sex?

26:12 Top five things people need to know to have great sex.

26:15 I mean, I think education is the obvious number one.

26:18 If you know your body specifically and you

26:22 know how to like education number one,

26:23 communication number two is every sexual experience

26:26 you have is a new sexual experience.

26:28 I mean, even with the same partner and so this idea,

26:32 you know, from uh encounter to encounter is going to change.

26:36 There are numerous different ways that people can experience pleasure.

26:40 There's so many different ways that you can, you know,

26:42 learn about each other's bodies and areas of pleasure.

26:46 There's always more learning to do.

26:47 And then if you have a different sexual encounter with somebody else,

26:49 whole new ball game, right?

26:50 And so the more you understand your body

26:52 and then you can talk about it with the person,

26:54 you know, obviously the more fun you're going to have

26:56 and you get to decide how much fun you have.

26:58 So I would say education, communication, you know,

27:02 again great sex is biocschosocial and I think we minimize I think

27:07 on the male side we minimize psychosocial

27:11 and on the female side we minimize biology.

27:15 Yeah.

27:14 And I think we need to do

27:15 a lot better about understanding that everybody is biology

27:18 with feelings and you know sort of an upbringing

27:21 and baggage like we all have that.

27:23 And I think that's important is is that, you know,

27:26 I think there's a whole lot more biology than we give it credit for.

27:29 Everybody's too serious these days.

27:31 Everything's so serious and terrible and awful

27:35 and um it's really hard to we've been through a lot.

27:38 I think pandemic wrecked us and we

27:40 did nothing to heal from the collective trauma

27:44 of pandemic and we are in this giant

27:46 sex recession where people are not connecting.

27:49 They're not communicating.

27:51 They are in their little insular bubbles, you know,

27:55 surrounded by people who are saying all the same

27:56 things that they are and they're really struggling.

27:59 And sex is supposed to be fun and joyful and pleasurable.

28:04 And again, people, there's a lot of bad stuff out there.

28:08 And so, we have to find ways to bring the fun back.

28:12 I think um because people deserve pleasure.

28:15 You deserve pleasure.

28:15 You deserve fun.

28:16 But on the flip side,

28:17 like no one's ever died because they didn't have an orgasm, right?

28:20 Like this is the other challenge.

28:21 Well, you could argue that maybe they have died.

28:23 We just can't attribute it exactly to the orgasms.

28:26 Not enough orgasms.

28:28 I mean, you know, because there is a mortality benefit to more sex, right?

28:31 So, there's actually data that supports that people

28:33 who have sex 52 times a year,

28:35 like once a week, live longer than people who don't.

28:38 I think there's cardiovascular benefit.

28:39 I think it's connection.

28:41 I think it's movement.

28:42 I think being able to have sex, right?

28:44 Sex is a high contact sport.

28:46 And so, um, and and what I find is there are no age

28:51 limits to when people like you don't ever have to stop having sex.

28:55 You can at any point stop having sex.

28:57 But if it's important to you and your partner, then it's important.

29:00 It should be important to your doctors and there

29:02 should be ways to sort of have pleasure.

29:04 And then also knowing that penetration is not the only pathway to great sex.

29:08 Absolutely.

29:08 And you know, we've talked about it here on this channel,

29:10 but like on this podcast about like how you

29:12 need a certain V2 max to have sex, right?

29:15 And so if you don't take care of your health in a multitude of ways,

29:18 specifically resistance training and cardiovascular

29:21 training in some shape or form,

29:23 like at some point it may become physically difficult for you to have sex.

29:27 And so if that's important to you, that needs to be a part of your lifestyle.

29:30 And it's really important that if you have a vagina

29:33 and you are in menopause age that things do change.

29:36 It is a very hormonally sensitive structure.

29:39 And so without hormones, the tissue gets thin, it gets raw, it gets irritated.

29:43 And not only is there vaginal dryness, but significant pain with sex.

29:47 And as so many of your listeners know,

29:50 it also comes with a lot of urinary problems, frequency, urgency, leakage,

29:53 and then you can be very high risk of urinary tract infections.

29:57 And so using vaginal hormones can be lifesaving

30:01 uh for anybody of any age, of any history, um to really help uh so sex isn't

30:08 painful and that you don't get urinary tract infections.

30:10 Yeah.

30:10 And we've said it before, we'll say it again.

30:12 There is no risk of cancer, blood clots,

30:15 stroke, really anything untoward with vaginal hormones.

30:18 Yeah.

30:18 So these local lowd dose vaginal hormones is essentially micro doing.

30:23 It's super small uh dose and it absolutely heals the tissue.

30:27 It improves lubrication.

30:29 Uh it changes the pH in the microbiome and so all

30:32 the good bacteria can grow and the bad bacteria get suppressed.

30:35 Um and it it truly is better than Viagra, right?

30:38 So it female Viagra truly exists because it helps with arousal,

30:42 it helps with orgasm.

30:44 So this is vaginal estrogen or vaginal DHEA.

30:46 There's a cream you could do twice a week.

30:48 There's a suppository you could do twice a week.

30:51 Vaginal DHEA is every night.

30:52 So you could choose any of those options.

30:54 There's even a ring you could set it and forget it for 3 months.

30:57 And so um this is why we we

30:59 actually helped publish guidelines last year by the American

31:02 Urologic Association on this issue which is

31:04 called genital urinary syndrome of menopause or GSM.

31:08 And we have developed all these free trainings um on YouTube.

31:12 We have a whole YouTube channel about it on our website.

31:14 We have a whole pocket guide of like bring a piece of paper

31:17 to your doctor say hey I want this prescription which links to all

31:20 the information because uh actually one

31:22 of our colleagues just published on this is

31:24 like Medicare patients with a diagnosis

31:27 of this problem 9% get a prescription nine

31:31 nine you know that's wild to me because you I know you

31:34 you know this but we prescribe this like candy like every woman who

31:38 is permenopausal or menopausal and has symptoms or even doesn't have symptoms

31:43 but may be worried about gang symptoms gets offered this in in my clinic.

31:47 9%.

31:48 You are a unicorn.

31:49 You're a magician unicorn.

31:51 We appreciate you greatly.

31:53 Um that's wild.

31:54 That's wild to me.

31:55 9%.

31:56 So sad.

31:57 It really is.

31:58 It's it's as if look if if a man came

32:00 in with erectile dysfunction n everyone is getting offered viagis

32:06 but not every woman is getting offered like this is these 9% with a diagnosis.

32:10 Like that's what's so depressing because it's so

32:12 much so many people have this problem that is

32:15 are not getting a diagnosis code and so

32:17 e those with a diagnosis 9% get a prescription.

32:20 So we have so much work to do.

32:22 This is why we just do not stop yelling.

32:25 Yeah.

32:25 It's so important.

32:26 So we've talked about exercise and we've talked about hormones.

32:30 What other like lifestyle diet changes do you think

32:34 people need to make to have great sexual desire,

32:37 arousal, and just sexual function?

32:39 I mean truly if it's good for your heart, it's good for your genitals.

32:42 And so anything, you know,

32:44 there's a the data is a little bit anytime you have nutrition data,

32:47 exercise data, it's a little murky.

32:49 Um there's been some data on Mediterranean diet.

32:51 Um you want to fix sleep apnea.

32:53 You need to be sleeping.

32:55 You want to check hormones, testosterone.

32:57 If you're a woman, you want to consider menopause hormone therapy.

33:00 Um we know dopamine is very important.

33:02 So a lot of medications like anti-depressants can

33:05 hurt sexual health either lower libido or delay orgasm.

33:08 And so there are medications that could boost libido.

33:11 We have two FDA approved medication.

33:13 One is Atti, one is Vilei that help with low libido,

33:17 but also work with other sexual problems.

33:19 So it's they help with arousal and orgasm and satisfaction as well,

33:22 which are great to have in our toolbox.

33:24 And so and the other thing that we've

33:26 published on recently is really devices and erotica.

33:29 And and we as clinicians must get comfortable talking

33:32 to our patients about devices and erotica because uh they work.

33:37 They're fabulous.

33:38 They're great education tools and it gives

33:40 your patients permission and getting them to understand.

33:43 I think we need to do a better job of bringing in devices

33:46 into the bedroom and getting everyone

33:47 on board with it because we wear eyelasses.

33:50 We uh you know we get all sorts of other aids that we need or or things

33:54 that I get in my car to drive like I need my phone to check my email like

33:59 we have like weighted blankets and weighted eye masks

34:02 and you know fancy mattress pads and all sorts of stuff.

34:05 We use technology for so many things, right?

34:08 We are.

34:08 And so getting comfortable and and again devices,

34:12 the device industry is so deliciously beautiful now compared to, you know,

34:18 sort of when we were growing up.

34:19 And so it's you can go on Amazon.

34:21 You can, you know, you can really find it at CVS today.

34:25 And again, understanding that vibration can be extremely helpful to access

34:29 the clitoris and uh the internal sort of parts of the clitoris.

34:33 And so it doesn't make you a bad partner.

34:35 It actually makes you a good partner if you bring in devices into the bedroom.

34:38 And so we really want to encourage um sort of that we

34:41 know uh erotica is very helpful whether it's reading erotica,

34:44 listening to erotica, watching erotica.

34:47 Again, the brain likes fantasy.

34:49 It likes new things.

34:50 It likes danger.

34:51 It likes it likes excitement.

34:53 It likes to think about things that you maybe would never do.

34:57 Um that doesn't mean you want to do them.

34:58 and it means that that you like watching

35:01 or listening or hearing about those types of things.

35:04 And so just giving that permission, it's it's funny.

35:06 I I um I was taking care of a patient the other day.

35:11 We go to a similar uh clinic uh

35:13 with veterans and I had this this veteran with me

35:16 and I was talking her with her about this show

35:19 on HBO that's gone crazy viral called Heated Rivalry.

35:22 And I say Heated like HRT is not hormone replacement therapy anymore.

35:25 It's heated rivalry therapy.

35:27 And it's this is a show um that went totally crazy viral.

35:31 Um it was a Canadian streaming show that got picked up by HBO

35:34 and is now one of the most watched ever TV shows right now.

35:38 And it's six episodes.

35:40 It's based off from a book and it's about these uh gay hockey players,

35:44 like these two very macho rival hockey players that fall in love and have

35:48 a lot of erotic moments and then also this very kind Have you watched it?

35:52 It's it's incredible.

35:53 How many times have you watched it?

35:54 Just once.

35:55 Okay, so you're you know you're I'm still a newbie.

35:57 Apparently 15% of people have watched it more than five times.

36:00 So people are really into this show.

36:03 And what has it's causing all of these heterosexual people to be like,

36:08 "Wow, I find watching two men have sex extremely pleasurable, erotic.

36:14 What does that say about me?" Or what does that mean for me?

36:16 And is this good?

36:17 Is this bad?

36:18 Why do I like this so much?

36:19 And it's not just the act of sex,

36:21 but it's watching their emotions, their feelings, and their relationship.

36:24 And so I was talking to this patient about it and she goes, "Wait,

36:27 I like really like that type of pornography and I I've never said that out

36:33 loud before and I thought there was something wrong with me." And I was like,

36:36 "No, no, there's nothing wrong with you.

36:38 like this is what lots of people like

36:39 and this is and you could see like her like

36:42 she just like light like everything kind of like

36:44 relaxed a little bit and she was so excited

36:47 to talk to me about it and I taught her about the so it was just again the more

36:51 we normalize and can talk about these things people

36:54 feel a lot less sort of alone in this

36:57 absolutely I mean look it's it's it's fantasy it doesn't mean that you

37:00 necessarily want to participate you just want to watch it or you

37:03 just enjoy it like who cares right but yeah absolutely I mean

37:06 there's just there's there's so much

37:08 importance in in giving people permission, right?

37:10 Especially like we you and I see older patients, particularly veterans, right?

37:14 And I will talk to them about toys and sometimes they're like,

37:17 "Oh, no." Like they they're so shut off to it.

37:20 But I've also had patients like, "Well, I've never tried.

37:22 Which one should I get?

37:23 What should I do?" And I think it's

37:24 really important like I'll I'll tell my male patients,

37:27 I'll be, you know, you can get like vibrating cock rings, right?

37:30 And that can be great to help you maintain an erection,

37:33 also be pleasurable for your partner and you.

37:36 um or if you're having trouble getting to if you're having delayed ejaculation,

37:41 sometimes these toys can really help.

37:43 And so I think just realizing like yes, it's okay.

37:46 You're allowed to experiment and try different things.

37:48 Absolutely.

37:48 The clitoris likes vibration.

37:50 The penis also likes vibration.

37:51 The paranium likes vibration.

37:53 Uh and so getting devices for couples

37:56 and playing with devices and different devices.

37:59 Again, sex is supposed to be fun.

38:01 It's supposed to be joyful.

38:02 It's supposed to be adult playtime and and playful.

38:05 And so if you're not talking about it, trying new things, doing, you know,

38:09 it's going to get a little stale and a little bit, you know, maybe lonely.

38:13 And so this is where I think people tend to go

38:16 into their own heads or their own spaces and live

38:19 their own sex lives sort of by themselves because they're afraid

38:22 of sort of communicating and having these conversations with their partners.

38:26 Absolutely.

38:27 You talked about Viagra.

38:28 Uh there was we recently published a paper on looking at Viagra

38:32 for cardiovascular risk mitigation or basically

38:35 reducing cardiovascular risk in post-menopausal women.

38:38 What did you find?

38:40 Well, this was just a wonderful paper that was

38:42 just recently published in the journal of sexual medicine where

38:44 it's more in theory of like here we know

38:47 that men who take Viagrais have decreased risk of cardiovascular problems,

38:51 strokes, heart attacks, actually at least less dementia.

38:54 uh which is so fascinating because these are

38:57 um sort of increase blood flow you know more

39:00 than to just your penis but they increase blood

39:01 flow and they help with all of these things.

39:04 Now, we know when you give women Viagra seialis,

39:06 it increases blood flow to their clitoris.

39:08 They have better arousal.

39:09 It's just that nobody prescribes this to women

39:11 because women aren't complaining of arousal problems.

39:14 Typically, they've got dryness, they've got pain, they have low libido.

39:18 And so, we use a lot of these drugs sort

39:20 of as an adjunct to these other things that we do.

39:23 But we, this paper really looked at, well,

39:25 why aren't we looking at this for cardiovascular benefit in women?

39:29 And it's so frustrating because in order to pull off a trial,

39:32 you need money and these are generic drugs that you

39:36 know there's not a lot of money in this.

39:37 And so and you also have to get your cardio cardiology people to care which is

39:42 very hard to do right because as a urologist

39:44 it's hard to look at cardiovascular markers.

39:46 Um so there's a lot of interest in this and we would love to pull off a study.

39:50 Um but we just got to figure out how.

39:51 Yeah.

39:51 I think it's interesting you know I've

39:53 heard this before that women don't complain

39:54 of arousal issues but I don't think they

39:56 have the language to complain about arousal issues.

39:58 is like they don't really know what that means outside of like oh

40:01 maybe my lubrication is inadequate which is not all of arousal right I think

40:05 there's more to it and they can't see their arousal like they can't see

40:09 an erection of their clitoris necessarily and so I think they don't really know

40:14 it's a huge problem in sex research because as we say shit

40:17 in shit out right if you're if you have bad data that you're working

40:21 with you're going to get a bad like you're not going to have

40:23 anything that makes sense and the way we ask the questions are so bad.

40:28 And women have like with men it's okay but your erection is different than

40:33 your orgasm which is different than

40:35 your ejaculate which is different than your libido

40:37 and we tend to lump like do you have female sexual dysfunction right like

40:41 it's sort of like like when I go to conferences like this is listen I

40:44 just went to a conf big conference Mayo Clinic and you have a like

40:48 a whole panel about different aspects of erectile

40:51 dysfunction and then it's like okay you get 15 minutes to talk about all

40:54 of female sexual dysfunction you know and you're

40:57 just you can never get into the weeds because you're still staying so broad,

41:02 which I'm glad I'm grateful that I had

41:03 the opportunity to speak on this, but again,

41:05 it's so challenging because we do we've got libido problems,

41:08 arousal problems, orgasm problems, and then pain,

41:11 and then there's hormones that play a role in all of it as well.

41:15 Absolutely.

41:15 And I think it is it is so important to think about all

41:18 those different things for women listening

41:20 or for partners who care about their female partners.

41:23 Like figure out what is really try to figure out what you're feeling.

41:27 Try to articulate it.

41:29 Don't be afraid to like really go in the weeds.

41:31 Whatever you can say about what you're

41:32 feeling because it gives us more information, right?

41:35 You not your doctor may not have the tools,

41:38 but they they certainly can find out.

41:40 They can look into it and they can ask.

41:42 And I think the other thing is like if a doctor says, "Oh,

41:45 go drink a glass of wine or you're okay." The right answer would be,

41:48 "I don't know what to do for you, but I can find someone who to refer to."

41:52 I give you a perfect example.

41:54 Uh I had a a DM just uh a couple days

41:57 ago from a patient of mine who uh is a fellow

42:01 physician and her husband went to the doctor and he's

42:04 got some low testosterone and the primary care doctor says, "Oh,

42:07 we got to give you testosterone." and they

42:10 gave him testosterone at not the dose I

42:12 would give but they gave him testosterone

42:14 and she says well you know I'm on testosterone

42:18 and he scoffs at her and says there's

42:20 no data for women on testosterone and there's

42:23 no possible reason why you should need

42:25 that and so he's he literally doesn't know

42:27 the data there's global consensus by the way

42:29 that testosterone works for women for libido global

42:32 consensus and he's confidently telling this woman who

42:36 is a doctor who knows the data who

42:38 is benefit benefiting from testosterone has been life-changing

42:41 for her and she he's telling her that there's

42:44 no data and she shouldn't be taking

42:46 testosterone while he is prescribing her husband testosterone.

42:49 I mean, you cannot make this stuff up.

42:51 So, why can't why when it comes to women's health can

42:54 you just like just say like this is not my specialty.

42:57 This is not my area of expertise.

42:59 Like, how hard is it to say those words?

43:01 Yeah.

43:02 I I really don't understand like if you

43:04 just don't know like you are misinformed, right?

43:06 That doctor is misinformed.

43:08 Maybe there wasn't data when he was training, right?

43:11 But there is now and he's misinformed.

43:13 It's frustrating.

43:14 It really, really is.

43:16 Let's talk about um the ulvar vestibule.

43:19 So, I think this is a part of ulvar

43:22 anatomy that every woman and partners should know

43:25 about because it's it's really valuable and important

43:28 and a cause of pain for a lot of people.

43:30 so important and it is so wild how basic anatomy is completely

43:36 missed on the doctor and the patient and it gets completely hidden.

43:40 So we talked about those inner wings, those labia minora.

43:43 Well, if you spread them to the side like a book, you open them up like a book.

43:48 Then right in front of your face is

43:50 an ovalshaped strip of tissue that surrounds the urethra,

43:53 the tube that you pee through,

43:55 and it surrounds the opening of the vagina, which is the inside part.

43:59 And that tissue is called the ulvar vestibule.

44:01 Now, it's very sensitive hormonally mediated tissue.

44:07 And so if you think of like the outside

44:09 of your cheek and the inside of your cheek,

44:12 they're very close together, but they're very different, right?

44:15 One is very skin and thick and tough,

44:18 and the inside of your cheek is very delicate, very sensitive,

44:21 and you know, would react, so you know,

44:23 would react differently to different, you know, sort of things.

44:26 And so the skin of the labia majora and the labia minora are are skin.

44:30 They're tougher.

44:31 And then this strip of tissue right

44:33 at the opening is like the inside of your cheek.

44:35 It's like this very delicate mucosal surface that is

44:39 essentially the same as the the bladder, right?

44:42 So the bladder turns into the urethra and then

44:45 the same tissue surrounds the opening of the vulva and vagina.

44:50 It's called the vestibule because it's sort of the entrance

44:52 like as you then go inside to the vaginal canal.

44:56 This area is often the reason why people have pain with sex, pain with tampons,

45:04 uh UTI, interstitial cyitis, um you know,

45:07 uh post-ex pain, you know, things like that.

45:10 It is often in this tissue.

45:12 And because this tissue is so sensitive to hormones, as I always say,

45:16 when you play with hormones,

45:17 there are consequences, sometimes good, sometimes bad.

45:20 Things like birth control pills can affect this tissue,

45:22 breastfeeding, um menopause, gender affirming hormone therapy,

45:27 um you know, surgical menopause,

45:29 um uh breast cancer therapies that affect hormones.

45:32 There are so many medicines uh and things people do,

45:35 acne medications that can affect testosterone levels because

45:38 this tissue is very sensitive to both estrogen and testosterone.

45:41 And also a lot of inflammation can happen on this tissue.

45:45 And so we see increase in mass cell issues come up uh in this tissue as well.

45:50 And so the problem your doctor often was not taught

45:54 that this exists nor were they ever taught how to examine it.

45:57 It's very easy to examine by the way.

45:58 You spread the labia minor open.

45:59 You take a Q-tip and you poke at the tissue and if it hurts you have a problem.

46:03 It shouldn't hurt.

46:03 But what do the doctors do is they take a speculum and they put it

46:07 into the vagina and then they open the speculum

46:09 and it completely bypasses so you can't see it.

46:12 So your doctor will say, "Oh, everything looks normal.

46:15 Put the speculum in.

46:16 Oh, everything looks normal.

46:18 You're normal.

46:18 This is all in your head." And that has been going on for decades and decades.

46:22 Women are told their bodies are normal.

46:24 It's all in their head.

46:25 to the point where patients come to see me and they're like,

46:28 "I've been to 10 doctors and no one's been able to figure

46:31 out why I have pain and I don't think you're going

46:33 to be able to find it either and you get that Q-tip

46:35 out and you find their pain because they don't have pain everywhere.

46:38 They just have pain in this part of their body

46:40 and and their eye they just go like they they're in disbelief,

46:44 right, that you can find their pain.

46:45 It is it is so important and and you mentioned many things that affect it.

46:49 Another thing that sometimes we see right is when women get recurrent

46:53 yeast infections or recurrent um STI this can also affect the vestibule.

46:58 Yeah, absolutely.

46:59 It's very sensitive tissue.

47:01 So any kind of infection can bring inflammation and then

47:04 again sex we said is a high contact sport.

47:06 So if you have something scraping against

47:08 this tissue creating like an inflammatory response.

47:12 It's kind of like people will describe it

47:13 like sandpaper like shards of glass like cutting,

47:16 burning, stinging, cracking, uh tearing.

47:19 These are sort of the words that we get from people.

47:21 And for some people they can't have penetrative activities.

47:24 For some people they can but they are going to pay for it later.

47:27 Um and for some people it affects their uh urinary health.

47:31 So they got more frequency urgency.

47:33 Um they've get constipation.

47:35 This one's wild.

47:35 I get patients who don't can't have sex but their pelvic floor muscles are

47:40 so tight they have horrible constipation and that's

47:42 sort of their only sort of symptom.

47:44 This tissue again is so hormonally sensitive and so we want to make

47:48 sure it has optimi optimal hormone hormones whether it's a vaginal DHEA topical

47:54 estrogen a topical estrogen testosterone you

47:57 want to keep it hormonally healthy if

47:58 a patient's on birth control pills we often try to get them to have

48:01 a hormonal IUD which doesn't affect hormones as much and then uh you

48:05 also want to look at their pelvic floors so so the muscles underneath

48:10 can cause pain here so working

48:12 with pelvic floor physical therapists Sometimes we'll

48:14 put Botox in pelvic floor muscles which

48:16 can be sort of life-changing for patients.

48:19 Um and then you know sometimes there's

48:21 an inflammatory thing uh that's happening that you have

48:24 to navigate as well and very rarely we'll need

48:26 to do surgery on this part of the body.

48:28 Yeah.

48:28 Yeah.

48:29 And you've mentioned birth control a few times.

48:31 So one you mentioned it earlier when you talked about

48:32 the labia shrinking and another when we just talked about the vestibial.

48:37 So let's talk a little bit how that works and why does it change the hormones.

48:40 Yeah.

48:40 So uh uh I love birth control as a concept, right?

48:44 I love the idea for women having control over their bodies and when they

48:47 reproduce and pregnancy is extremely dangerous with high

48:50 complication rates and people die in childirth.

48:53 So I I love the idea of contraception.

48:55 I love vasectomies too.

48:56 They're they're a great form of contraception.

48:58 Um but again as I said when you play with hormones there are consequences.

49:02 Sometimes those are very good consequences like not getting

49:05 pregnant and sometimes they're you know sort of negative consequences.

49:08 everyone who takes oral birth control pills that stop the the way

49:12 they work is they stop the ovary from making its own estrogen,

49:16 progesterone, and testosterone.

49:18 And so, anyone who takes a birth control

49:20 pill turns off their ovaries production of testosterone.

49:24 And if we believe testosterone is important for the pelvis,

49:28 the vulva, the clitoris,

49:31 uh the libido, which we know, we know the penis is a testosterone driven organ.

49:36 We know male libido is affected,

49:38 male muscle, male bone is affected by testosterone.

49:41 And so if we think like it it just makes logical sense and we have data too,

49:44 but like it makes logical sense that it's important for women.

49:47 And so um that's how birth control works.

49:50 So what you see and the data is mixed here because

49:52 again many people on birth control feel very confident in their sexuality.

49:56 They feel more in control.

49:57 So they have better sex life, better sex outcomes.

50:00 But there is a growing uh area

50:02 of research where you see people with lower libido,

50:04 it's pain with sex, you know, vulvar complaints, things like that.

50:08 And I think it's important that we

50:10 explain these possible side effects to our patients.

50:13 Now, IUDs don't usually turn off the ovary and so they can pre like prevent.

50:18 We like IUDs because they are you set it and forget it,

50:21 but then also they your body is still making its own hormones.

50:25 Absolutely.

50:26 Um so important.

50:27 I think so important for I I I mean I talked about this with Irwin too,

50:30 but I think it's so important that we're not actually counseling women on this.

50:34 Like I wasn't counsled on it when I got put on birth control when I was younger.

50:37 I don't think that women are getting the appropriate

50:39 counseling about how this could affect their hormones.

50:41 I think that's where so much of the anger is right now is people are just like,

50:46 "Could you just tell me?" Right?

50:48 You're not You didn't tell me about pmenopause.

50:50 You didn't tell me about menopause.

50:51 You didn't tell me about my clitoris and the full anatomy.

50:54 Every time I've gone viral,

50:56 it is for that exact reason where people are like, "Shit,

51:00 why didn't I know that like I am a smart, educated,

51:03 went to C like and I didn't know that, right?" Like,

51:06 and so it's it's kind of giving those moments of like, "Hey,

51:09 I bet you didn't know this about your body." And I think women are just pissed.

51:14 I think the men are pissed, too,

51:16 cuz like they want to know what's going on, too.

51:18 Like I can't tell you how cool it is to have

51:20 a a male partner stand behind me and see a vulvar

51:24 vestibule exam and realize that he's like like it's not him

51:28 like that she has essentially a sunburn on her vulva that hurts.

51:31 And so it's there's this empathy that comes

51:33 with actually seeing the problem and understanding the problem.

51:36 And so again, birth control is not good or bad, right or wrong,

51:40 but like any medicine or anything you do or do not do to your body,

51:45 there are potential risks and benefits and side effects.

51:48 Absolutely.

51:48 And the thing is I think that I don't know if it's taught in OBGYn residency,

51:52 but I don't remember learning this in medical school about oral contraceptives.

51:55 So I once got into a screaming match

51:58 uh with a eurog gynecologist in my area when

52:00 I was a resident because I was following

52:02 the data and actually knew what was going on.

52:04 And uh and he and I yelled.

52:07 We're yelling at each other and he

52:08 was saying birth control doesn't have side effects.

52:10 It doesn't have side effect.

52:11 And I and I was just like yell he doesn't like me very much, but that's okay.

52:16 Well, you're right and he's wrong.

52:18 So, it is what it is.

52:20 In the vein of hormones, let's talk a little bit about menopause.

52:23 You learned how to treat menopause as did I after leaving residency,

52:28 after sort of being trained as urology,

52:30 realizing that there was just not many people.

52:32 In fact, we had this conversation.

52:33 I don't know if you remember it actually when we were in your clinic

52:37 and I said well who's treat teach who's treating menopause and you said

52:41 I said aren't the gynecologists treating it and you said no no one's treating

52:44 it and that was actually what prompted me to learn about it but why

52:47 do you think that one people are not learning it what prompted you

52:50 to learn about it medicine is a dumpster

52:53 fire of brokenness right now and probably

52:56 for a long time we have decided as a society that there is one

53:01 type of doctor that is responsible for everything that has to do with women.

53:05 And I'll tell you, the gynecologists are a little busy right now, right?

53:08 They get these 10-minute visits.

53:10 They put your legs up in stirrups.

53:12 They make sure you get your mammogram.

53:13 They they're responsible for your breast health,

53:15 your bone health, your brain health, your heart health.

53:18 They're responsible for you being safe and like, you know,

53:21 and like they are on call every few nights, up all night delivering babies,

53:26 dealing with emergency surgeries, like emergency life and death.

53:29 You and I have never had a call as bad

53:32 as what a weekly call is like for an OB/GYN.

53:35 And and no one cares.

53:37 Okay?

53:38 So, when you have a room where you deliver a dead baby and then you

53:42 go to the next room and it's the best moment of that person's life, right,

53:46 cuz they're having their first baby, let's just say,

53:48 and then you have to go to clinic the next

53:50 day to talk about someone's libido or hot flashes,

53:54 and you get 10 minutes to do it.

53:56 So, the idea that the gynecologist can do

53:58 this or and they're not taught any of this, by the way,

54:01 none of this in residency.

54:03 In fact, I was just at a conference and I was sitting at the bar and there

54:06 was a gynecologist sitting uh sitting there and she

54:09 didn't know who I was and and I said, "Oh, I'm a urologist.

54:12 I do sexual health." And she says, "Oh,

54:14 I like I I've never written a testosterone prescription.

54:17 Everyone's coming in asking me for testosterone." I said, "Oh, it's really easy.

54:20 I'm happy to tell you." And I explained it to her and I taught her the dosing.

54:24 And she looks at me and she goes, "Well,

54:27 maybe it's not because I'm afraid to write testosterone.

54:30 I just don't want to see these patients." She said, "They take too long.

54:34 They fill up your clinic.

54:35 I don't want to be known as the person who does this because

54:38 I do a whole lot of other things." And that's the truth bomb, right?

54:41 Like, and she does do a lot of other things and she does important things.

54:45 And so, the question is whose responsibility?

54:47 This is half the population.

54:49 And so, primary care is swamped, right?

54:52 Gynecology is swamped.

54:53 everyone else wants to be a surgeon.

54:55 Like, who takes care of these people?

54:58 It cannot be niche medicine.

55:00 And so, I we're struggling.

55:01 So, it's kind of all hands- on deck,

55:03 which is why I created a course to teach doctors how to prescribe

55:06 hormone therapy because no one else is stepping up to the plate, right?

55:09 Right now, how many ways can you learn how to prescribe a GLP-1?

55:12 Probably 572.

55:14 Like, if you go online, there's probably a million courses.

55:17 We have very few courses and and uh continuing medical

55:21 education to teach people how to write prescriptions for hormone therapy,

55:25 why you need to do why you should consider it, how to counsel patients,

55:29 but even just what dose and what pharmacy do you use?

55:32 So, it really doesn't exist and that's

55:34 crazy in 2026 that it really doesn't exist.

55:36 So, our friend Heather Hirs has a great course.

55:38 I started a course, right?

55:40 There are few now.

55:41 There's uh like Harvard's putting out an ICME

55:44 uh that's happening in March uh that people can go to, but there really aren't

55:47 that many opportunities to learn how to do this.

55:50 And it really is all hands- on deck.

55:52 Anyone who wants to learn how to do this, like join us.

55:55 We need you.

55:55 And we need evidence-based practitioners out there who are like really

55:59 able to meet patients where they are and give them customized advice.

56:04 Absolutely.

56:04 Because there are some serious consequences

56:06 to prescribing this the incorrect way, right?

56:09 And you can't just play with hormones, right?

56:12 Yeah.

56:12 You want, listen, you want knowledgeable clinicians and that unfortunately it's

56:18 getting it's very hard to find in the menopause space right now.

56:21 Um I think there are a lot of people

56:24 doing things in ways that maybe I wouldn't do them.

56:28 But patients are hungry for answers.

56:31 They just want to feel like themselves.

56:32 They want to feel like they're doing everything that they can do

56:35 to stay as strong and as healthy and as hot as possible.

56:39 And like patients deserve shared decision-m and they deserve to work

56:43 with someone who's going to like fight with them for them, right?

56:46 And fight alongside them.

56:48 Yeah.

56:48 Yeah.

56:48 Absolutely.

56:50 And I think that um you you sort

56:52 of describe menopause as a total body castration event,

56:57 which um I think it's it's really interesting way to put it because I

57:00 think you and I also see men with low testosterone and they feel horrible.

57:04 They feel miserable.

57:05 They don't feel like themselves.

57:07 They are not productive members of society like they used to be.

57:11 Um they're unhappy.

57:12 But this is what happens to every woman.

57:15 It's wild cuz I there is nothing more

57:17 joyful than taking a man who's got a testosterone

57:20 in the 200s getting them to like the five or 600s and with a weekly injection.

57:26 And I can't tell you they're like three minute visits where they're like,

57:29 "Ruben, I feel great.

57:31 I have so much energy.

57:33 I'm back at the gym.

57:34 My my partner is happy.

57:36 My libido is back up.

57:37 My pills are working fine for erections.

57:40 I'm so happy.

57:40 Please give me refills.

57:42 Blood counts look good.

57:43 Testosterone levels look good.

57:44 See you in 6 months.

57:45 Right?

57:46 Like the the joy like I have all these men male patients out there

57:50 who think I am the greatest human on earth for a three minute visit,

57:54 you know, after we counseledled and all

57:56 those things and they're feeling so good.

57:58 And and it's so funny because um you

58:01 know some of our other like our endocrinology colleagues,

58:03 our primary care colleagues,

58:05 they are not as sort of cavalier about male testosterone as the urologists are.

58:09 Like we really because we really love quality of life

58:11 and we love talking to patients about stuff like that.

58:13 And then these patients go back to those doctors and they're

58:16 like okay like you're you know like what do they say?

58:19 Like these patients are so happy.

58:21 Um and so well they just tell them their heart is gonna explode or something

58:25 which it's not.

58:26 It's not and that data is not.

58:28 So that's when men, you know, again, if you think of it like a gas tank,

58:32 their gas tank is like, you know, a little bit low.

58:34 It's like a quarter tank.

58:36 Every woman over the age of 50 goes to an empty tank.

58:39 It's it's fact.

58:40 It's castration.

58:41 It is no longer hormones.

58:43 And I'm sorry people don't like that word, but that's what's happening.

58:46 And we do not castrate men willy-nilly, nor should we castrate women the same,

58:52 you know, and sort of not fight back.

58:54 And we have tech like I would not be able

58:56 to see without my contact lenses like not at all.

58:59 Since first grade I would not I can't see anything.

59:01 Okay.

59:02 And so I use technology so that I can be

59:06 a surgeon and like live in this world and like do things.

59:09 So we have incredible bioididentical hormone

59:13 therapy that can help prevent osteoporosis,

59:17 help with hot flashes and night sweats,

59:18 help get you feeling like yourself again,

59:20 you know, help the genital and urinary symptoms.

59:23 I'm not going to apologize for wanting

59:25 my patients to optimize their sexual health, their quality of life,

59:29 and live their best life because I will tell you,

59:32 my grandmother was 90 in the nursing home with dementia and cracked ribs.

59:37 And that is not the life that I want, right?

59:39 Like that's not good aging to me, nor and if that's what I'm fighting against.

59:44 Like the data is so clear to me that it's about strength

59:49 and prevention and doing everything you

59:51 can while your body is functioning, right?

59:53 And so that includes eating well and exercising and lifting,

59:57 but it also includes discussions about hormone therapy.

1:00:01 Correct.

1:00:01 Absolutely.

1:00:02 So, let's talk about what actually happens to your entire

1:00:05 body when your estrogen drops during parmenopause and menopause.

1:00:10 It's super interesting.

1:00:11 So, actually in your 30s, your testosterone starts to drop.

1:00:15 And no one talks about this and I do think it's important.

1:00:17 It's actually not a menopause problem.

1:00:19 It's sort of as you age, I guess you could call it pmenopause.

1:00:23 Um, but but your testosterone start,

1:00:24 so you still might be having your periods normally,

1:00:27 but you still kind of don't feel like yourself.

1:00:29 Maybe your stress incontinence gets a little worse.

1:00:31 Maybe your libido goes a little bit down.

1:00:33 Maybe you're getting urinary tract infections or BV infections

1:00:36 or yeast infections every once in a while after sex,

1:00:39 but you just don't quite feel like you.

1:00:42 And menopause, the average age of menopause,

1:00:44 which is the full castration event where your estrogen is zero,

1:00:48 you know, that's kind of 45 to 55.

1:00:50 So all you 40year-olds out there, you're not too young, right?

1:00:53 Like 45 to 55 is a reasonable normal age to be fully menopausal.

1:00:58 Yeah, you recognized Ricky Martin at the Super Bowl, you should be listening.

1:01:03 Exactly.

1:01:04 And he's aging in reverse and I don't understand that at all.

1:01:06 It was literally amazing.

1:01:08 Um, but so, so if Perry menopause, if we say things start getting weird about

1:01:12 10 years before that, you're talking 35 to 45.

1:01:16 So for you 30-year-olds, like this is you're you're not too young.

1:01:19 I had a reporter just talk to me this morning about how the algorithm,

1:01:23 she's 39 and the algorithm is feeding her constant

1:01:26 things about pmenopause and it's creating a lot of anxiety.

1:01:29 I'm like kind of conflicted there because I was like,

1:01:31 you actually do need to learn about this.

1:01:33 You need to know what's happening because all I can

1:01:35 guarantee you ahead is shit's about to get weird, right?

1:01:38 And I think there's this whole timeline of people in their late 30s,

1:01:43 40s, and 50s where you really start to NLM not feeling like myself.

1:01:48 And it's kind of different for everyone.

1:01:50 And people fight back.

1:01:51 They're like, "Well, this is just aging." And like what's the difference, right?

1:01:55 Like I I don't know.

1:01:56 And like again, eyeglasses like I choose to wear contact lenses.

1:01:59 So why wouldn't you add hormones to help with some

1:02:03 of these symptoms if it helps you and if it works?

1:02:05 And really what are you afraid of?

1:02:06 So when I teach people, it's like sort of what are you scared of?

1:02:09 We give birth control pills all the time

1:02:11 to people this age which is very high dose

1:02:14 you know sort of very very highdosese synthetic hormone

1:02:17 therapy is is essentially so people are prescribing hormone

1:02:19 therapy they're just doing it it as the birth

1:02:21 control form and so we try to teach

1:02:23 like there are other ways to potentially do it

1:02:26 to try to alleviate some of your patient symptoms.

1:02:29 It's so important to to have these conversations.

1:02:32 And yes, everyone's experience is going to be different, right?

1:02:34 Not everyone is going to have this crazy chaotic hormonal

1:02:37 fluctuations just like everyone doesn't have crazy um periods, right?

1:02:42 Everyone is a little bit different

1:02:43 and and you shouldn't have really really painful periods,

1:02:45 but some people have more, some people have less, right?

1:02:47 There is a variation of normal.

1:02:49 Um and I think the similarly like your experience may be different,

1:02:52 but there is going to be a change.

1:02:54 And this is where I really like the education piece

1:02:57 because when I can educate my patients on the toolbox,

1:03:00 the different forms of hormone therapy, right?

1:03:02 We're talking estrogen, progesterone, testosterone for the whole body.

1:03:05 We're talking about vaginal hormones.

1:03:07 Um, when we talk about that toolbox that they all

1:03:10 have different products that you can use in different doses,

1:03:12 in different forms, the more my patients understand the toolbox,

1:03:16 the more they can play with the toolbox, right?

1:03:18 And they will find throughout their 40s and 50s,

1:03:21 they may play in different ways.

1:03:23 And it's not a one-sizefits-all, but the magic words for me is when

1:03:27 the patient comes back and says, "Ah, I'm back.

1:03:30 I feel like myself again, right?

1:03:31 We got it.

1:03:32 We we hit it right." And the challenge

1:03:34 with pmenopause is there's a lot of wild fluctuations.

1:03:37 And that is sort of a challenge, which is why birth control for some people is

1:03:40 a good idea because it it flattens out the fluctuations.

1:03:43 But there are other ways to consider doing it, too.

1:03:46 Yeah.

1:03:46 When do you determine like for someone who's on birth control,

1:03:49 should they just stay on it if they're doing

1:03:51 okay versus should they try to switch to menopausal therapy?

1:03:55 It's a completely individualized discussion.

1:03:58 I have many patients who choose to stay on it.

1:03:59 I have some who will add testosterone

1:04:01 because remember birth control shuts down your ovary.

1:04:03 It adds back fake estrogen and fake progesterine.

1:04:06 It doesn't do anything to testosterone.

1:04:08 I'm like, why don't they put testosterone in the birth control pill, right?

1:04:11 Like that would be great.

1:04:12 So, so we do have patients who add

1:04:14 testosterone and vaginal hormones to their birth control pill.

1:04:18 We have patients who choose to maybe get

1:04:20 an IUD and then use menopause hormone therapy with estrogen,

1:04:24 progesterone, testosterone, um you know,

1:04:26 sort of different variations of it and vaginal hormones of course

1:04:29 because actually even if you're on whole body hormone therapy,

1:04:32 vaginal hormones are still very much needed and and should be prescribed.

1:04:36 Absolutely.

1:04:37 The the one big thing that I talk about a lot is how it causes recurrent UTI.

1:04:41 And so I'll have women who are already on systemic hormone therapy,

1:04:44 but they're getting UTI and tell them you need

1:04:46 to start vaginal estrogen and they get confused because they're like,

1:04:48 I'm already on estrogen.

1:04:49 I said, well, no, it doesn't actually affect the local tissue.

1:04:52 So if you want the local benefits, meaning more lubrication,

1:04:55 no pain with sex, prevention of UTI, you need the vaginal.

1:04:59 And for anyone who's nerdy and listening,

1:05:00 we this is a guideline statement number

1:05:03 11 in the American Neurologic Association that says,

1:05:06 it's my favorite guideline statement that patients who are on systemic hormone

1:05:09 therapy should still be screened and offered

1:05:11 treatment for the genital urinary symptoms.

1:05:13 So we've got guidelines to pro, you know,

1:05:15 to really say this is something we should be offering.

1:05:18 Do you think, and this is obviously I

1:05:19 don't think we have clear data on this yet,

1:05:21 do you think that DHEA is better than regular estrogen?

1:05:26 I think if I h if I was in charge, which nobody ever wants that to happen,

1:05:32 um I would if vaginal DHEA were available,

1:05:35 it would be my first line because again,

1:05:38 we know that the genital tissue and the bladder tissue is androgen sensitive.

1:05:41 So, both estrogen and testosterone.

1:05:44 And DHEA is the only FDA approved product that we have that does both.

1:05:48 And so, I love it.

1:05:50 I think it's great.

1:05:51 um it's just often difficult for our patients

1:05:53 to access and and not always well covered.

1:05:55 But I think it's a fabulous product

1:05:57 and it's not the same as oral DHA supplements.

1:06:00 So vaginal DHEA that's prescribed by your doctor.

1:06:04 Correct.

1:06:04 Absolutely.

1:06:04 Um let's talk about I think the thing that patients struggle with when they're

1:06:07 starting menopausal therapy is that they it's

1:06:11 finding the right dose for them, right?

1:06:13 Because sometimes the estrogen is too high and they have bleeding or discomfort.

1:06:17 What is your approach to that?

1:06:18 How should patients approach that?

1:06:20 Yeah.

1:06:20 So again, it depends a little bit if they are per menopausal, right?

1:06:24 So you're normally a reproductive age,

1:06:26 your estrogen probably shifts between like 50 to 150 down to 50.

1:06:32 When you're pregnant, your estrogen is 3,000.

1:06:34 And when you're in menopause, it's zero.

1:06:36 And so we're looking at between zero and 3,000 as our range.

1:06:42 We don't want you to be up to 3,000 like pregnancy.

1:06:44 But if you're talking between zero and 150, you know,

1:06:47 that's kind of the range with which we often play.

1:06:51 Um, and it depends because in perry menopause,

1:06:54 your ovaries can do some wild things.

1:06:56 I've seen patients have estrogen like 900,

1:06:59 a thousand, you know, these wild high fluctuations.

1:07:02 And no one's trying to get those down.

1:07:04 Let's remind ourselves like no one's castrating those women.

1:07:07 No one's running around with those women

1:07:09 telling them their estrogen has to be lower.

1:07:11 no one's checking their estrogen levels.

1:07:14 And so, um, if you're in pmenopause,

1:07:16 there are patients who will start getting breast tenderness

1:07:18 a lot because the fluctuating hormones of their own ovaries doing,

1:07:22 um, they'll get hot flashes, they'll get night sweats,

1:07:24 and a lot of it is that fluctuation from 900 to zero and back back up.

1:07:29 And so, we try, at least with those patients,

1:07:31 I tend to either to try to like make their estrogen not zero.

1:07:35 So, I give them a little bit of gas in their tank,

1:07:37 but they may not need a a high

1:07:38 dose because their ovaries are still producing estrogen.

1:07:42 Now, if you've been fully menopausal for, you know,

1:07:45 haven't bled in over a year and you haven't had estrogen around,

1:07:48 then you may want to start with kind of a medium or low dose just to prevent,

1:07:51 you know, the side effects,

1:07:52 which can be breast tenderness, bleeding, things like that.

1:07:55 So, you go a little bit slower sometimes with those patients.

1:07:58 So, it really depends.

1:07:59 Again, it's not like a one-sizefits-all.

1:08:01 I often tell patients, start with 005, you know, and you know, cut it in half,

1:08:05 go up or down and kind of use a medium dose to kind of play with that.

1:08:08 Well, I think the other important thing what I tell my patients is like look,

1:08:11 it it is going to be variable.

1:08:13 Everyone is individual.

1:08:14 There's not more is not better and less is not like inferior.

1:08:18 It really depends on how your body responds to it.

1:08:20 And you know, it's interesting to me that we just

1:08:23 started talking about checking estrogen

1:08:25 levels on people getting transermal estrogen, meaning gels or patches,

1:08:29 because we've been doing that for testosterone for years because

1:08:32 we know that 20% of guys don't absorb their testosterone.

1:08:36 You're such a logical urologist.

1:08:38 I just I love your brain because it just uses

1:08:40 logic and unfortunately that doesn't exist in the real world.

1:08:44 Yeah, it's a challenge because we know

1:08:45 men don't absorb testosterone topically very well.

1:08:49 So why would women be all that different?

1:08:51 And and I think we struggle with this.

1:08:53 We do I do we do have patients that do not absorb the topical estrogens.

1:08:58 And so we play, you know, again,

1:08:59 there are role there's a role for oral estrogen,

1:09:01 there's a role for injectable estrogen.

1:09:04 And again, if you know the toolbox

1:09:05 and you have some understanding of the toolbox, you can play within the toolbox.

1:09:10 But um it is not not every patient who gets

1:09:12 the same dose of a patch absorbs it the same way.

1:09:16 Absolutely.

1:09:16 And and I think that it's so important that like Yeah.

1:09:18 It's okay to check the hormones.

1:09:20 Like I actually had a friend of mine, a mutual friend of ours,

1:09:22 call me like, "My gynecologist refuses to check my estrogen,

1:09:25 but I'm on trans dermal estrogen and I don't feel great

1:09:29 and I think I might not be absorbing it." And I was like,

1:09:31 "Yeah, it's very reasonable in that circumstance." What are

1:09:34 other circumstances where you think it's reasonable to check levels?

1:09:38 I mean, if you're on a good dose

1:09:40 of hormones and you're having symptoms still, right?

1:09:42 If you're still in hot flashes, night sweats,

1:09:45 you know, you're just not feeling good.

1:09:46 I'll tell my patients all the time, if you have like a really bad day,

1:09:49 you know, certainly you it doesn't mean it's going to be the answer,

1:09:52 but like I had a patient um she wore a fem ring and that's a ring,

1:09:57 an estrogen ring, highdose estrogen ring that goes in the vagina for 3 months.

1:10:01 She's a marathon runner, like super super elite athlete.

1:10:04 Um and she had been doing great and she

1:10:07 calls me one day and she's like, "I feel awful.

1:10:09 All my symptoms are back.

1:10:10 You know, I feel terrible." I said, "Oh my gosh, like how old is your ring?

1:10:13 You know, sometimes it runs out.

1:10:14 Let's check." So, she goes to the lab,

1:10:16 she gets her lab, and her estrogen is three, right?

1:10:19 And I was like, "This doesn't make sense.

1:10:21 You need to take your ring out and change it." And so,

1:10:23 she goes to the bathroom, she tries to take her ring out, and she can't find it.

1:10:26 So, what probably happened is she had a big bowel movement.

1:10:28 Something happened, she beared down, the ring fell out, and she didn't notice.

1:10:32 And so, she wasn't getting any estrogen.

1:10:34 And so, again, did we need the lab to tell us that?

1:10:37 No.

1:10:37 We probably could have started with the estrogen check for the ring,

1:10:40 but it's just a good story of like her symptoms,

1:10:43 you know, were telling us something was wrong, right?

1:10:45 What about before getting any therapy?

1:10:47 So, like I think there's a lot of confusion, right?

1:10:49 There's a lot of people getting blood tests and as you mentioned,

1:10:52 pmenopause is like a roller coaster and so

1:10:54 getting a random blood test is not useful.

1:10:57 But when is it useful for patients to check and how should they know

1:11:01 that they're getting a blood test that's

1:11:02 actually going to give them some information?

1:11:03 Uh it's a huge challenge cuz again I think when patients

1:11:07 come in and say I want you to check my hormones.

1:11:10 That's the language they're using to say I don't feel good and I want

1:11:14 something to help me and I want validation here and I want numbers to help

1:11:19 explain the way that I feel because I think you're going to just tell

1:11:22 me to do more yoga and deep breathing and there has to be another reason.

1:11:26 Right?

1:11:26 And I think in moments like that, we need

1:11:28 to take a second and instead of putting our, well,

1:11:31 let me tell you how hormones work and let me tell you

1:11:34 why you're wrong and and you're stupid for even asking me that question.

1:11:38 It it doesn't help.

1:11:39 Um, I think there are a lot of labs out there right now

1:11:42 that are pushing a lot of hormone

1:11:44 testing and a lot of expensive hormone testing, which I don't agree with.

1:11:48 But I think if we understand the roller coaster of the hormone fluctuations,

1:11:52 then there are certain points where you could check.

1:11:55 The guidelines are clear that you should check a you can check

1:11:57 a total testosterone at any point and that is very guideline driven.

1:12:00 So if your doctor says we that hormones are not helpful,

1:12:03 you could show them the testosterone guidelines

1:12:04 and say hey a total testosterone is helpful.

1:12:07 Um, and then I find again, and this is just one of the ways that I was taught,

1:12:12 is that when you check if you have your period,

1:12:15 um, that's kind of you're at your low.

1:12:16 And so if you check around the time where you have your period, so maybe day 1,

1:12:20 2, or three, you know, check that estrogen level, how low do you go, right?

1:12:24 If I have a patient who's 38 and her day two estrogen is seven,

1:12:30 I don't love that for her bones, right?

1:12:32 I don't love it.

1:12:33 And do I have all the data in the world to say that she should be?

1:12:35 But it tells a story.

1:12:36 It helps me tell a story.

1:12:38 Now the next day her estrogen could go to 200, right?

1:12:42 And that's a challenge, right?

1:12:43 Vis and and the more your patients

1:12:45 understand the roller coaster and they understand that.

1:12:47 And I think again um the way technology is advancing so quickly,

1:12:51 I think this is going to be a very interesting

1:12:54 space to watch because I think we've got continuous glucose monitors.

1:12:57 I think we'll have continuous hormone monitors not so far in the future.

1:13:00 I agree.

1:13:01 And I think the book is going to have to be rewritten because I

1:13:03 bet you most people do not follow the book that we were all taught.

1:13:07 And so we have to be for any doctors listening or clinicians listening,

1:13:12 we have to be Plato.

1:13:14 Everything is different now.

1:13:16 There are so many things in medicine

1:13:18 that did not exist when we were in training.

1:13:19 And we have to be willing to be humble

1:13:23 and and and have some humility and this ability to say like, "Wow,

1:13:27 we're going to learn new things and we're going

1:13:28 to get it wrong sometimes and we're going to get we

1:13:30 got this wrong and we're going to get more things

1:13:32 wrong." But like we have to be Plato a little bit.

1:13:35 Yeah, absolutely.

1:13:35 And I think it's it's just so important and yeah,

1:13:37 I do think continuous hormone monitoring is coming

1:13:40 and I think it's going to be very useful,

1:13:42 but also it's going to be very prayed upon.

1:13:46 It's going to have a lot of unintended consequences

1:13:48 and there's going to and like with all things

1:13:50 there's going to be right there are people who

1:13:52 are and we've seen it with the continuous glucose

1:13:55 monitors right the amount of anxiety that it

1:13:57 builds the amount of you know there's a lot

1:13:58 of bad you see all the people who talk

1:14:00 about it non-stop and then you stop hearing from them

1:14:02 for a while right and they put it away

1:14:03 they're obsessed with it and then they put it

1:14:05 away and and so I think like all things

1:14:08 like it's it's like I mean look at operating

1:14:11 with a robot right you and I didn't train

1:14:13 you know fully on the robot started to come

1:14:15 in when we kind of towards the end of our training

1:14:17 and now they use a robot for everything, right?

1:14:19 And it becomes the technology is there.

1:14:21 So, you're like, "Okay, we're going to use it." And then like,

1:14:23 "Do you need it?" Well, now we don't know how to do open surgery,

1:14:26 you know, like there's there's pros and cons.

1:14:28 Let's talk about women with IUDs or anything that's suppressing Well,

1:14:33 IUDs I think are more specific because you can't really stop an IUD.

1:14:36 Um, how do they know when they are going to be

1:14:39 in pmenopause or when hormone therapy might be useful for them?

1:14:42 So, IDs are great because they make you not bleed,

1:14:45 but they're also a little bit challenging because then you

1:14:47 don't know um sort of what's going on with your periods.

1:14:50 Are you skipping periods?

1:14:51 Where are you?

1:14:52 And I think this again is where education

1:14:53 is so important of Nflm not feeling like myself.

1:14:57 So, I have a friend who wasn't feeling like herself and just kind of was

1:15:01 feeling awful and she had an IUD in place and we um we spot checked,

1:15:05 you know, her hormone levels.

1:15:06 Uh but you didn't even need to do that.

1:15:08 We started her on an estrogen patch because

1:15:11 her uterus is protected and she started an estrogen patch.

1:15:14 U she was on vaginal estrogen and she

1:15:16 decided to use testosterone and when I tell

1:15:18 you she's a completely like transformed human being

1:15:23 and she's in her early 40s and it

1:15:25 is just like night and day and she has an energy and a you know

1:15:30 she's at the gym way more and her libido is up and she's feeling like herself.

1:15:35 Um, which is great because she's got a big seauite position now and she's,

1:15:39 you know, working harder than ever, but she feels like she can do it.

1:15:41 And it's so fun to watch.

1:15:43 Um, but again, is that what everybody should do?

1:15:45 No.

1:15:46 But like you have to have these conversations

1:15:47 of like what do you want to, you know,

1:15:49 what makes sense for you and how are you feeling?

1:15:52 Absolutely.

1:15:53 The other thing there's been a lot of discussion

1:15:54 about brain health and heart health benefits with hormone therapy,

1:15:59 which is sort of controversial in the data.

1:16:01 What how do you consult patients on that?

1:16:03 I am not a uh neurology researcher nor a cardiovascular researcher.

1:16:08 I always say like I'm a boner doctor, not a bone doctor.

1:16:11 And I I I really it to me it's such a ridiculous conversation that is happening

1:16:16 in this fake place called the internet where

1:16:19 people are fighting over nonreality things that are happening.

1:16:23 Everyone's saying is like, "Oh,

1:16:25 the influencers are telling women to take hormone therapy to prevent

1:16:28 dementia and they're evil influencers." None of the influencers are saying that.

1:16:33 Influencers are saying, "Hey, look at Lisa Muscone's data.

1:16:36 Hey, look at all this interesting data out there.

1:16:39 You know, libido helps with your testosterone helps with libido.

1:16:42 Libido is a mood.

1:16:43 Like, could it affect, you know,

1:16:44 we see some some studies show benefits for brain?

1:16:47 You know, we have data showing decreased cardiovascular disease." So,

1:16:50 so people are talking about data.

1:16:53 No one is seeing a patient in their clinic who says

1:16:56 the only reason I want hormone therapy is to prevent heart attacks.

1:16:59 like that patient doesn't exist.

1:17:01 And to say that patient exists like come

1:17:04 find me because that patient has low libido, urinary tract infections,

1:17:08 osteopenia, she has hot flashes, night sweats,

1:17:10 and she's not sleeping and she's not feeling like herself.

1:17:13 That is like many indications where hormone therapy is

1:17:16 absolutely beneficial for that patient and should be discussed.

1:17:19 So the idea that patients are coming to you saying, "Well,

1:17:21 I need to take this to prevent dementia." That's not true.

1:17:24 Patients are coming in saying, "I don't feel like myself.

1:17:26 I have all these symptoms and I'm interested in the brain data out there.

1:17:30 Hey, so am I.

1:17:31 I'm also interested in the brain data out there.

1:17:33 So, I think it's a ridiculous conversation

1:17:36 that's happening and it's distracting from the point,

1:17:39 the real problem, which is nobody knows

1:17:41 how to write goddamn hormone prescriptions, right?

1:17:43 Like, like I don't care that they're fighting

1:17:46 about this on the internet when you are giving

1:17:48 the primary care doctors an excuse of saying

1:17:51 I don't need to learn how to do this.

1:17:52 You do need to learn how to do this.

1:17:54 In fact, you absolutely should know how to write an estrogen prescription,

1:17:58 a progesterone prescription, a vaginal hormone prescription, and yes,

1:18:01 you can learn how to write a testosterone prescription.

1:18:03 And so, every doctor, honestly,

1:18:05 I think orthopedic surgeons should learn how to write

1:18:07 hormone therapy prescriptions because people die of fractures.

1:18:11 Like, it's wild to me.

1:18:13 I think neurologists should learn how to write hormone prescriptions.

1:18:16 I think rheumatologists absolutely should learn

1:18:18 how to write hormone therapy prescriptions.

1:18:20 Literally, endocrinologists don't know how

1:18:22 to write hormone therapy prescriptions.

1:18:23 I go and speak at academic centers at endocrinology departments and I was

1:18:27 like how embarrassing that a urologist

1:18:29 is teaching a bunch of endocrinologists how

1:18:31 to write estrogen patches right like this is basic stuff but we are fighting

1:18:35 about the minutiae on the internet it boggles my mind how dumb that conversation

1:18:40 is yeah and I think the way I tell people is like yes

1:18:43 there may be benefit is not 100% proven if you ask me based

1:18:46 on what I see in men's health because there's an abundance of data

1:18:50 on testosterone benefits that probably there is But I can't say for sure, right?

1:18:54 Like I can't say with a 100% certainty that it's going

1:18:58 to cause any prevention of dementia or it's going to do be cardioprotective.

1:19:02 But um you know to some degree but cardio

1:19:04 protection there is some good data on that.

1:19:06 But I think in general like it doesn't Yeah, you're right.

1:19:08 They're not there for that purpose.

1:19:09 There was an interesting paper that you were involved in that looked

1:19:13 at treating menopause might actually impact

1:19:15 patients who are considering plastic surgery.

1:19:18 Oh, I we wrote a paper with a plastic surgery resident

1:19:22 about why the plastic surgeon needs to learn about hormone therapy.

1:19:26 Just like we were talking like we need

1:19:27 plastic surgeons to learn about hormone therapy because listen,

1:19:32 you have hormone receptors in all of your body.

1:19:34 Your skin, your hair, your nails, like your bowels,

1:19:37 your your your wound healing is so important.

1:19:39 Like hormones are so important for wound healing.

1:19:41 And so plastic surgeons are doing laboplastes,

1:19:45 they're doing clitoreral surgeries,

1:19:47 they're doing aesthetic things, they're doing skin care,

1:19:50 they are doing so many things that are

1:19:53 around and and breast tummy tucks and breast reconstruction.

1:19:58 They are always working with permenopausal and menopausal patients.

1:20:02 And for them to say like, oh, hormone therapy is not my lane.

1:20:05 We can't do this is ridiculous.

1:20:07 So, it was really just a paper going through

1:20:09 sort of why the plastic surgeons should care about this.

1:20:12 I really I want a paper in every journal.

1:20:15 You know, this is why the geriatrician should care

1:20:16 about this and this is why the ID doctor

1:20:18 should care about this because truly there is no

1:20:21 field of medicine that shouldn't care about this topic.

1:20:25 You know, it's so interesting.

1:20:26 I that there's so much fear around hormones

1:20:29 and this is true because I saw you know there

1:20:32 was obviously you were on the FDA panel for women

1:20:35 and estrogen and removing that blackbox warning for estrogen.

1:20:39 Uh but there's also a panel that was

1:20:40 on testosterone and it was mostly about male testosterone.

1:20:44 There was some discussion about female testosterone but it was very interesting.

1:20:47 I was part of this group.

1:20:49 I don't remember which one it was,

1:20:50 but it was this group on online and there was a lot of doctors complaining

1:20:54 about how how this panel was so biased and how testosterone is so bad for you.

1:20:59 And I was literally sitting there and shocked because I was like,

1:21:03 one, they don't know the data.

1:21:05 Like, they're literally sitting there based on some

1:21:08 education they got years ago that's inaccurate.

1:21:11 Again, it's this group think mentality and sort

1:21:15 of this idea of once you believe something,

1:21:19 it is really hard to change people's minds.

1:21:22 And I think this is where we're

1:21:23 struggling because no one everyone's excited about GLPs.

1:21:27 Everyone's excited about GLPs, right?

1:21:29 You don't have the pitchforks of the people a little bit,

1:21:32 but like most people are learning about them, learning how to prescribe them.

1:21:35 They're taking courses.

1:21:36 They're getting mentored on it.

1:21:38 And they're all about the GLP ones, right?

1:21:41 It's new and new things people can get like keep an open mind.

1:21:44 Oh, this is new.

1:21:45 Let me learn about it.

1:21:46 Well, they already have a an emotional

1:21:50 attachment to the term estrogen and testosterone.

1:21:53 And there's emotions behind it.

1:21:55 And it has to do with these really

1:21:56 annoying patients who come asking for, you know,

1:22:00 things that that you think they don't need.

1:22:01 These really annoying patients that take too much time and they're

1:22:04 asking for things that you don't know how to do.

1:22:06 And so, you're uncomfortable with it.

1:22:07 So, you shut them down.

1:22:09 And instead of just telling them you don't know, you know,

1:22:11 and then they go to the meta-pas and they get it from, you know,

1:22:14 somebody who took a weekend course and that so they must be all be snake oil,

1:22:17 so it must all be snake oil.

1:22:19 And it's simply not true, right?

1:22:21 But again, these clinicians are trying in their minds

1:22:25 to deal with life and death medicine.

1:22:27 They're preventing they're screening for cancer.

1:22:30 They're dealing with high blood pressure and diabetes.

1:22:33 they don't have time to worry about people's libidos or erections

1:22:37 or um you know muscle mass and things like that.

1:22:40 And you're seeing patients more and more care about prevention and care about

1:22:45 sort of health and it's new and the doctors aren't keeping up so much.

1:22:49 There's so much bias.

1:22:51 There's so much group think and even we see

1:22:54 it um we see a lot of the emotion like

1:22:56 the way an endocrinologist is taught to do male testosterone

1:22:59 is very different than the way a urologist is taught.

1:23:02 Um, and it's way worse on the female side.

1:23:05 What is one thing that you changed your mind on about sexual

1:23:09 medicine or menopause therapy since you started uh specializing in the space?

1:23:14 Oo, uh, great question.

1:23:15 I I'm constantly changing my mind.

1:23:17 I'm constantly learning new things, um, which I love.

1:23:21 I'm always trying to listen and learn from colleagues.

1:23:23 I would say libido is a really perfect example.

1:23:27 When I came out of my fellowship in 2016,

1:23:31 uh we had one drug approved for low libido

1:23:33 and um the other one was approved I think in 2018

1:23:37 and in my mind I was sort of a surgeon and I

1:23:40 you know you you do surgical things and like libido that's

1:23:43 all the psychosocial stuff and it really was I think

1:23:46 a lecture by Irwin who you interviewed you know where it it

1:23:50 showed sort of the neurobiology of libido and we see patients

1:23:55 all the time with uh SSRI or anti-depressant induced sexual problems,

1:24:00 low libido, delayed orgasm, cognitive, like just challenges with sexual health.

1:24:04 And there was like this moment I like

1:24:06 remember this like light bulb moment like holy crap,

1:24:09 if medicine can bot your sexual health, can medicine improve your sexual health?

1:24:14 And I got really sort of like, oh,

1:24:16 and whose job is it to have these conversations with patients?

1:24:20 Because why aren't the psychiatrists prescribing these medicines?

1:24:24 You know, why aren't the gynecologist?

1:24:25 why aren't the primary care?

1:24:26 And like no one taught them how to do it.

1:24:29 And so I got really loud about it because if not me, then who, right?

1:24:32 If I'm not out there prescribing these things

1:24:34 and looking like no one else thinks this is their lane because no one else

1:24:39 cares enough about sexual health to like actually, you know, prescribe.

1:24:43 So I use So I've been a big prescriber and sort of interested

1:24:46 in these medicines for low libido and hormone therapy for low libido.

1:24:50 And we've seen just the magic.

1:24:51 I mean, we've seen do they work in everybody?

1:24:54 No.

1:24:54 But when they work, it's just so you're a hero.

1:24:57 I mean, you're just a hero when you can help raise dopamine

1:25:01 in someone's body and they get this surge of sort of dopamine,

1:25:06 sexual health, libido, and it's so fun.

1:25:08 So, I think that was a big um a big aha moment for me.

1:25:12 Yeah.

1:25:12 And you know, I think that the even bigger thing that we haven't touched

1:25:15 on too much is that sexual health is a biomarker of your health, right?

1:25:20 It is not just this thing you do for fun, right?

1:25:23 Yeah, of course it's fun and it's pleasurable,

1:25:25 but moreover, it's it's interconnected into your entire being, right?

1:25:29 It's interconnected into your heart health, your brain health,

1:25:32 and like it should be everybody's lane.

1:25:34 It should be.

1:25:35 And as you mentioned,

1:25:36 I think that it's just so important that anyone who's listening,

1:25:39 if you're struggling with sex, it is not something to be ashamed of or something

1:25:42 that we just talk about with certain doctors.

1:25:44 Like, it is a part of your life and we should make it normal to talk about.

1:25:48 Yeah.

1:25:49 it.

1:25:49 You know, I've been told over and over in my career,

1:25:51 even with people you used to work with, right, of like what you do is weird.

1:25:55 What you do is weird.

1:25:56 You're not going to make enough money.

1:25:57 This is not medicine doesn't value this.

1:26:00 This is not real medicine.

1:26:02 Um, and you know, we were just talking about how everybody

1:26:05 always minimizes us and what we do and what we're capable of.

1:26:10 And yet when we pull it out, like people are so interested in this.

1:26:13 Everyone is affected by this.

1:26:15 And that's why it's funny because I lecture a lot um

1:26:17 and I teach a lot about this stuff and and I

1:26:21 don't really speak differently when I'm talking to a group

1:26:23 of of clinicians versus patients because

1:26:26 everyone knows nothing and nobody knows anything.

1:26:30 And so I talk to and I know that they're all patients.

1:26:33 Everyone in that audience is a patient.

1:26:36 And I know because they send me they come to see me or they send me

1:26:39 their their partners and and it is wild how no one was taught how to do this.

1:26:45 It never ceases to amaze me like how is it that I

1:26:48 have been able to get on the the the platforms and the stages

1:26:53 that I've gotten on like I you know the smart the more

1:26:55 I learn the more I feel like I don't know anything.

1:26:58 Um and yet you know that's how bad it is.

1:27:00 It's like there really aren't enough people out there talking about

1:27:03 this, teaching about this, and there

1:27:05 certainly aren't enough people writing the prescriptions.

1:27:08 And that's the challenge is cuz everyone deserves access to sexual health,

1:27:12 quality of life, sleep, libido, orgasms, you know, feeling like yourself.

1:27:17 Like, everybody deserves that.

1:27:19 Uh, and and we should be fighting for that a whole lot more.

1:27:22 Yeah.

1:27:22 And and I think the bigger issue is not that people don't care,

1:27:25 it's that medicine doesn't care.

1:27:26 is that the insurance companies don't

1:27:29 reimburse the care for these issues, right?

1:27:31 They don't reimburse you for the time you spend talking to patients about this.

1:27:35 And some of the codes aren't even reimbursed, right?

1:27:37 Many of the female sexual codes are not reimbursed by insurance.

1:27:41 And so you for for so a regular physician who

1:27:45 needs to put food on the table doesn't have is

1:27:48 not able to see these patients because they literally cannot

1:27:51 like cannot make ends meet by seeing patients like this.

1:27:55 And so it's it's really comes down to what

1:27:57 medicine values or not medicine but what insurance companies value

1:28:01 which yeah it's and uh it's a huge problem.

1:28:04 So where should people find you?

1:28:06 Where can they find out practice

1:28:08 your research your course everything you're working on?

1:28:10 Uh yeah so uh our website's a great place to go rachelrubenmd.com.

1:28:14 Um we have amazing newsletter that you should sign up for.

1:28:18 Uh our courses can be found on there.

1:28:20 Our free um education can be found on there.

1:28:23 Uh we have a research team that meets once a month.

1:28:25 So if you're a student listening or you

1:28:27 want to get involved in research, please join us.

1:28:29 Um and we are always coming up with new ideas and new ways to reach people.

1:28:34 So uh follow me on Instagram, Dr.

1:28:36 Rachel Rubin.

1:28:37 So Dr.

1:28:38 Rachel Rubin, and uh we'd love for you to join along.

1:28:41 Awesome.

1:28:42 So we end our podcast with four questions that we ask everyone.

1:28:45 It doesn't have to be about sexual medicine.

1:28:46 It can be about anything you want.

1:28:48 So what is something you know now in life that you wish you knew earlier?

1:28:51 I should have been kinder to myself and that progress over perfection.

1:28:56 Absolutely.

1:28:57 Absolutely.

1:28:57 What's a non-negotiable?

1:28:59 Something you have to do every day.

1:29:00 I sleep I sleep like eight hours a night.

1:29:03 Really?

1:29:04 Yeah.

1:29:04 Oh, I love that.

1:29:05 I'm neither an early bird or a night owl.

1:29:07 It's actually wild how productive I am because

1:29:10 I cannot stay up late or get up early.

1:29:14 But that's good.

1:29:14 What's a life hack or health hack you'd share with people?

1:29:17 It's all mindset work.

1:29:19 The whole story.

1:29:20 Everything is about your mindset work.

1:29:22 And the more you invest in constant mindset work, the better your life truly is.

1:29:28 Um because your brain is sort of like uh the default of your brain is weeds.

1:29:33 And if you don't cultivate and actually work on it all the time,

1:29:37 the weeds will continue to grow.

1:29:39 And uh that has been absolutely life-changing.

1:29:42 If you couldn't be a physician, a urologist,

1:29:45 an entrepreneur as you are now, what would you be?

1:29:48 I always joke that I would name nail polish

1:29:50 colors because they always have really witty fun names,

1:29:53 but I don't actually ever get my nails painted.

1:29:55 So, I don't know.

1:29:56 With the plight of a surgeon, we never get our nails done.

1:29:58 I know.

1:29:58 I know.

1:29:59 Uh that's the best answer I can come up with.

1:30:02 What have you thought of a nail polish color that you

1:30:04 like like a red or like a I don't know.

1:30:06 It would probably be clearly the best or something like that.

1:30:09 Yeah.

1:30:10 Yeah.

1:30:10 I love that.

1:30:11 All right.

1:30:11 Thank you.

1:30:12 Did you guys love that conversation?

1:30:13 Because I know I did.

1:30:15 And if you are enjoying this conversation and you've been a longtime listener,

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1:30:20 Hit the subscribe button or the follow button

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1:30:35 Thank you guys so much.