348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT)

Rubin emphasizes this stepwise approach because many patients demand ‘give me everything at once,’ which almost always leads to side effects and confusion. She starts with estrogen because vasomotor symptoms are often the most disruptive, then adds progesterone mainly for uterine protection (with bonus sleep benefits), and finally testosterone for sexual and genitourinary health. She monitors by symptoms first but uses LCMS estradiol and FSH levels to troubleshoot—e.g., if a Femring user has a return of hot flashes and estradiol is <20 pg/mL, she knows the ring is failing early and can add a patch toward the end of the cycle. She finds labs particularly useful when absorption is questionable, such as with patches that don’t stick or patients who don’t absorb topicals well.

Rubin categorizes women into three groups: lovers, neutrals, and haters. She emphasizes that even the haters need uterine protection, so she never simply drops progesterone; she finds an alternative. She often uses the vaginal route as a first rescue, and if that fails, places a progestin IUD. Interestingly, some women still get the sleep benefit from vaginal progesterone. She also points out that many clinicians don’t know that taking progesterone with a fat-containing meal substantially improves absorption.

Rubin is passionate about testosterone because her patients return saying ‘I feel like me again’—it is often the missing piece after estrogen and progesterone are optimized. She explains the FDA’s double standard: a 5-year, billion-dollar study proved safety and efficacy in women, but the FDA demanded 5 more years and another billion, so all pharmaceutical companies abandoned the field. She now relies on Testim 1% gel (or generic equivalents) with a tiny dose. She educates women that testosterone does not cause masculinization at physiologic doses; the biggest side effect is fear. She also notes that vaginal DHEA (Intrarosa) provides local androgens and is a great second-line for GSM.

This is Rubin’s flagship topic. She details the history from ‘senile vagina’ to GSM and the fierce battle to include the word ‘urinary.’ She and her mentor published that universal Medicare use would save $6–22 billion/year. She recounts trying to get vaginal estrogen for her ventilated mother in the ICU, where the entire medical hierarchy refused because of the box warning—a tragedy that repeats daily. She says vaginal estrogen is ‘better than Viagra’ for women because it treats everything Viagra does for men plus prevents UTIs, yet no one knows about it. She is building a case to remove the box warning and is horrified the FDA refuses to act without industry pressure.

Rubin finds IUDs ideal for perimenopause because they solve three problems at once: uterine protection, bleeding control, and birth control. She often combines an IUD with an estrogen patch and a touch of testosterone for a ‘set it and forget it’ regimen. She cautions that even with an IUD, some women still enjoy the sleep effects of a low dose of vaginal progesterone, which is safe to add.

Rubin and Attia strongly agree on this. The ‘book’ says never check labs, and the Instagram fringe checks everything; they both land in the middle. Rubin uses labs to show perimenopausal chaos to patients and to confirm that a Femring user whose estradiol is undetectable needs a new ring. Attia adds that FSH is a great marker: an FSH of 78 with estradiol of 40 tells him the woman needs more estrogen.

Rubin calls this the only time she compounds a product, because FDA-approved options don’t address this specific tissue. She teaches that during a pelvic exam, pressing the labia minora with a Q-tip causes no pain, but pressing the vestibule around the urethra reproduces the patient’s exact pain—often misdiagnosed as interstitial cystitis or recurrent UTI. This compounded cream can be curative. She wishes a company would study and manufacture it.

Rubin details how the results were announced via a press conference before the paper was published, scaring women and physicians overnight. The data actually showed that estrogen alone reduced breast cancer risk, colon cancer, fractures, diabetes, and even overall mortality, yet the news focused on a small incidence increase in the combined group. Even that increase disappeared when proper placebo groups were used. The labeling on all estrogen products still carries the black-box warning, despite the evidence. The fallout was so severe that less than 4% of eligible women now receive HRT, and most internal medicine and OB/GYN physicians receive zero menopause training.

Rubin prescribes off-label male topical testosterone gel (1%) at one-tenth the male dose, applied to the calf, and sees dramatic improvements in libido, orgasm, and sexual identity. She notes that vaginal DHEA also provides local androgens and reduces UTIs. Celebrities like Halle Berry and Kate Winslet now openly use testosterone, which is helping to destigmatize it.

Rubin argues that all doctors—internists, cardiologists, psychiatrists, rheumatologists—should know that menopause affects their organs. Estrogen prevents colon cancer and osteoporosis, yet GI and bone doctors don’t prescribe it. Psychiatrists are told their malpractice won’t cover HRT, even though they use hormone-based postpartum depression drugs. The result is that 84 million women over 40 compete for a few thousand menopause-certified providers, leading many to seek care from questionable online pellet clinics.

Rubin published that universal Medicare use of vaginal estrogen would save $6–22 billion per year by preventing UTIs, ICU admissions, and sepsis. She fought the FDA to remove the box warning but was told it would require industry petition—yet the WHI destroyed the industry. Even when she tried to give her own mother vaginal estrogen in the ICU, the pharmacy and multiple teams refused because of the box warning. She had to teach the entire transplant and ICU team every week to get it administered.

Rubin personalizes by trying oral first; if mood worsens, switch to vaginal route to bypass first-pass metabolism and reduce neuropsychiatric effects. If that fails, a progestin IUD or synthetic progestin can be used. Some women still get the sleep benefits of micronized progesterone even with an IUD by using a low dose vaginally.