Welcome to The Pelvic Messenger, presented by Beyond Basics Physical Therapy, where we’re breaking the silence on pelvic health and pelvic pain. Hosted by our very own Dr. Amy Stein and Dr. Corey Hazama, two leading experts in the field, this podcast is your go-to source whether you’re a patient seeking answers or a healthcare provider looking to enhance your understanding and treatment strategies. From discussing the latest research and insights to sharing personal stories of triumph and resilience, The Pelvic Messenger is your companion on the journey toward healing and empowerment.
Dr. Amy Stein, DPT
Hi, I’m Dr. Amy Stein, owner and founder of Beyond Basics Physical Therapy in New York City and author of Heal Pelvic Pain and Beating Endo. I am so excited to have Dr. Rachel Rubin, who I’ve known for a very long time through ISSWSH which is the International Study for the Society of Women’s Sexual Health. We are going to be talking about the Intersection of Hormones, Pelvic Health and Sexual Function in Women. For those that don’t know this wonderful physician that we’re all listening to today, can you explain a little bit about your background?
Dr. Rachel Rubin, MD
Yeah, absolutely. I’m so thrilled to be here. I’ve been a big Amy Stein fan for I think as long as Amy Stein has been around. I am a urologist. I did my fellowship training in something called sexual medicine, which means I take care of all genders and I deal with issues of libido, arousal, orgasm, and pain. We do a lot of hormones and menopause. We do a lot of just sexual health. We do a lot of education, advocacy, and research.
I started my own practice about two and a half years ago in the Washington DC area, although we just opened a clinic in LA. So we are now Bicoastal. My co-fellow Ashley Winter has just joined me and is gonna be seeing patients in LA. We’re growing just a team that really deeply cares about people and spends a lot of time with them. A lot of doctors don’t really spend time with you, don’t get to know you, don’t really care about your goals and what you want, and especially when it comes to sexual health and quality of life. We do things differently and we are just having so much fun.
The Anatomy of the Clitoris and its Role in Sexual Function
Dr. Amy Stein, DPT
Oh, that’s awesome. I’ve been a big fan of you always for as long as I’ve known you, as well as Dr. Winter. That’s so exciting. Congrats. That’s really exciting. I noticed your necklace there. Can you first describe to everyone what that necklace is?
Dr. Rachel Rubin, MD
Yes, I joke, I wear a clitoris around my neck. It’s a custom made clitoris, a wonderful artist, Sophia Wallace in New York City does custom design clitoral necklaces. This one has my birthstone, a sapphire in it. And you know no one really knows the true anatomy of the clitoris. So if I’m with politicians, they think it’s just a nice piece of jewelry. They have no idea that I am literally talking about female genitalia.
Dr. Amy Stein, DPT
This wasn’t part of our questions, but can you explain a little bit about why we only see a tiny, tiny portion of it visibly, but what you just showed us? Because I think that’s fascinating.
Dr. Rachel Rubin, MD
Yeah, it’s really fascinating. You know, I am a urologist. I am a penis doctor. We have a whole field of medicine devoted to the male penis, and yet no one even studies or examines or cares at all about the equivalent of the penis, which is the clitoris. The clitoris and the penis are exactly the same thing. They’re made up of the same tissue. They have all the same parts to it. It’s just that the penis, half of it’s outside the body and half of it’s inside the body. The clitoris, most of it’s inside the body. I have a vulva here. I should get one that’s not clear. Basically, you’ve got labia majora, you’ve got labia minora, these inner wings. And if you follow these labia minora, you get to the hood of the clitoris. It’s actually covered, essentially the same as men who have foreskin. It is the version in women. You should be able to pull back that hood and see the head of the clitoris like the head of a penis. But about 23% of women, it’s stuck together or what’s called a clitoral adhesion. We’ve done a lot of research on that as well. But the rest of the clitoris, this big organ is all underneath the skin and the muscles and the tissue. And so you have to activate it in different ways. The clitoris, like the penis, has a shaft, it has a body, it has legs that go all the way down to the butt bones. You should be very familiar with the pelvic floor, because Amy Stein, she basically invented the pelvic floor. The clitoris goes all the way down to the butt bones. Many people have to activate the clitoris to have an orgasm, need stimulation either externally up here or with vibration over the labia majora. Now some people like inside or vaginal stimulation because that gets to the underside of the clitoris, but we know that less than 15% of women can orgasm from penetration alone. That’s why you have to know where your clitoris is and how it functions to properly activate it, but it gets erect the same way a penis gets erect. It stimulates the same way a penis stimulates.
Dr. Amy Stein, DPT
Yeah, those are great points because I’m sure you have the same experience with women at all ages, they come in and they’re not sure where their clitoris is and they may think it’s the urethra opening or another area within that area. It’s really important to educate for sure. Can you explain a little bit more about how you would actually treat someone that has those adhesions that you’re speaking of?
Dr. Rachel Rubin, MD
It’s really interesting, right? The hood of the clitoris, I always wear sleeves so I can kind of show this. Do people see the video or they only hear the podcast?
Dr. Amy Stein, DPT
Actually both. We have both.
Dr. Rachel Rubin, MD
Okay, good. So if you’re listening to it, but you want to see the visuals, I just showed some diagrams and some models and stuff like that. If you think of my sleeve as being completely covering my fist, right, that’s what a clitoris with a hood sort of looks like. And you should be able to pull it all back and see what looks like the head of a penis that has a rim around it. That’s called the corona. What happens is about 23% of women it’s stuck and it may be mildly stuck where you can see most of the head, but it’s stuck on the edges. It may be moderately stuck where you can see a sliver of the head, but it’s pretty stuck together. Or it could be so severe that you really can’t see the head at all. Here’s the problem, my friends. No doctor on Earth is taught or ever examines this part of the body. It is not a routine part of the physical exam. In fact, when I was in medical school, which wasn’t that long ago, okay, let’s be real, I have lot of gray hair now, it was a long time ago. But when I was in medical school, we were taught don’t touch the clitoris because you don’t wanna make your patient uncomfortable. That’s a no zone. So we don’t even teach doctors even how to look at it, which means if something goes wrong, who do you go to, to help you when something goes wrong? And so we are the first group to publish on this really, and we continue to publish on it because it turns out when you get rid of those adhesions, you can improve orgasm, you can improve arousal, you can improve satisfaction, and you can decrease the pain because a lot of women, when it’s stuck together and they get that erection, it hurts, it doesn’t feel good. So how many women are walking around saying, I don’t like oral sex. I don’t like when my partner touches me there. It doesn’t feel good. Everyone assumes it’s your psychosocial traumatic upbringing and nobody says, look, there are oils and skin cells that build up underneath and it’s irritated and it hurts. If you ever wake up with eye crusties, you’ve got these eye crusties and you just kind of pick them out and like you got to kind of separate your eye to open it in the morning. It’s essentially the same thing that can happen to the clitoris because these oils and skin cells can kind of build up underneath. But no one’s looking, you guys, no one’s looking under the hood. So that’s why you gotta get your mirrors out and you have to start knowing what’s going on down there because that part of your body is supposed to give you pleasure. It’s supposed to give your partner pleasure. Like sex is literally how we procreate as a society. So we gotta start talking about it.
Dr. Amy Stein, DPT
I agree and that’s also an interesting point about how you’re not educated on it because when I first started pelvic floor PT, I was also like, you know, stay away from that area. You can look, but don’t touch type of thing. And same with our male patients, I was even taught, don’t even look. But now it’s like, okay, there could be adhesions even in our, yeah, it’s muscle.
Dr. Rachel Rubin, MD
It’s muscle, it’s tissue, it’s part of the body. So again, the more we understand that these parts are just body parts, like anything else, we really can start to learn about them.
Dr. Amy Stein, DPT
Yeah, I totally agree.
The Impact of Hormones on Pelvic Floor Health
Dr. Amy Stein, DPT
Can you explain more about the role of the different hormones in sexual function, estrogen, testosterone, any others? It’s probably a whole hour topic in itself, but I’ve learned a ton from you and I would love our listeners to be able to hear what you have to say.
Dr. Rachel Rubin, MD
I think the more we learn, the more we obviously have to understand that there’s a lot we don’t know. But as far as we know today, the ovary does three things. It makes estrogen, progesterone, and testosterone. It probably does a whole lot more than that, but we’ll keep it simple. Throughout your reproductive time, when puberty happens, you get a surge of hormones. Little kids don’t really have high levels of hormones fluctuating in their body. And then puberty happens and their bodies literally morph. Their genitals actually change. Little girls have no labia minora and then they go through puberty and they grow big labia minora. The clitoris grows. The opening, you couldn’t put a tampon in a little girl and then they grow and puberty happens and it’s a place where tampons can go because the whole tissue is very hormone sensitive. Puberty creates all these changes, changes in breast health. Teenagers are these horny individuals who have high sex drives. They may have acne and oily skin, but they learn about masturbation and they start exploring their bodies and they can orgasm and all these things are happening because of a surge in hormones.
Hormones are really important for sexual health. There is a biological basis to sexual health. In fact, many people will notice that around ovulation time, they get this surge of sort of oh I’m interested in sex. And it’s because the body has a little surge of testosterone to say, hey, go make a baby. Now’s the right window. So hormones are really, really important for sexual health. But we do a lot to mess up hormones or to play around with hormones. I say this all the time, I’m kind of a broken record, but when you play with hormones, there are consequences, sometimes really good ones and sometimes really bad ones, but there are always consequences. If you’re on a birth control pill, that can be great for not having a baby, which is a pro if that’s what you want, but it may cause some lowered libido or some pain with intercourse because of the way birth control pills interact with your testosterone levels or lower your testosterone levels.
Any kind of changes in hormones can affect your sexual health. We just published on a groundbreaking paradigm shift of when you are lactating, you develop genital and urinary symptoms around breastfeeding and lactation, which we’re calling GSL or genitourinary syndrome of lactation. Because when you’re breastfeeding, you have menopausal level of hormones, they go very low. And so you get low libido, you get pain with sex, you get urinary tract infections. We know in menopause or perimenopause, these hormones are really fluctuating. It’s going to affect your urinary health, your sexual health, your libido. We love to talk about the psychosocial effects of sexual health. And I love, listen, y ‘all, everyone benefits from sex therapy and pelvic floor physical therapy. There is no human on earth who cannot benefit from sex therapy and pelvic floor physical therapy. I always say, Amy, if you have a pelvis, you should go to a pelvic floor physical therapist. But there is so much biology as well. That is sort of that third part that people like to minimize and also make women think that it’s actually not important, and it is so important. And the reason Amy has me on, thank goodness, is because she learned early on, way ahead of most physical therapists actually, that her job is so much better when she involves mental health and biological health in the pelvic floor world. That’s where that trifecta is, the magic sauce that we find.
Dr. Amy Stein, DPT
Yes, so true. I appreciate the comments about the physical therapy, of course. And then it’s so important to have you involved in these scenarios.
Listening to Patients and Considering the Whole Person
Dr. Amy Stein, DPT
As you said, the biology part, is there a test that you do for these patients for hormones, to see what’s going on with the hormones so that they understand more of what’s happening in their body?
Dr. Rachel Rubin, MD
More important than a blood test is education because your hormones are changing long before your periods stop. Your hormones are changing long before the numbers and the lab values are changing. I was just texting with my friend who’s a very popular Twitter urogynecologist and she very publicly had an ovary removed from an emergency surgery. And she said, man, I haven’t been feeling right the past couple of months and my numbers, my labs are fine, everything’s fine, but I put an estrogen patch on and holy hell, it’s like I can see color again. She said this very publicly on the internet and I said, my God, it’s a perfect story because the numbers did not reflect what was going on. Yet when you listen to the person and you listen to the symptoms and you give the right treatments, magic can ensue. It’s a little more complex than, oh I did a blood test, I don’t qualify for this, there’s a lot of nuance. So it’s not that we never get blood tests. We use blood tests as a snapshot. But what’s so fascinating about perimenopause is that your blood test one day may be completely different two days later. It’s not completely explaining everything that’s going on in your body and unfortunately, right now we don’t have a continuous glucose monitor type of thing for hormones. Maybe one day we will, and maybe one day we’ll get more data from something like that. But it’s really important to know that just because your numbers look “normal” or your doctor won’t even get them, your symptoms are real. It’s real if you’re not feeling like yourself and you’re feeling like you’re falling apart, those are hormonal changes.
Dr. Amy Stein, DPT
Yes, so basically what you’re saying is you really have to listen to your patients and not just rely on tests. I agree.
Dr. Rachel Rubin, MD
You have to see a doctor who will take time to listen to you. Y’all medicine is so broken, right? We are taught in medicine, this is real, that you’re only supposed to have one problem, right? I just went to a dermatologist. It was the worst visit I’ve ever had in my life. I went for a skin check. But I also want to know what I should be putting on my face, and I also have a question about a rash I’ve been having, also I want to talk about this other thing. Well, she was only there to do the skin check and even bringing up another skin problem was like I was an insane person, right? She was out the door and she knew I was a doctor. That was the craziest part of the story. The point is a doctor wants you to have one problem. But in perimenopause, you don’t have one problem. You have dry eye, you have headaches, you have heart palpitations, you have frozen shoulder, you have a dry vagina, you’re getting urinary tract infections and you don’t feel like yourself because you actually do have one problem. But your doctor didn’t learn that perimenopause has treatment options and they can actually talk to you and explain to you what’s going on in your body because we don’t teach doctors about menopause.
Dr. Amy Stein, DPT
Right, right. So onto another area of topic with hormones is how would you explain that hormones affect the pelvic floor muscle function?
Dr. Rachel Rubin, MD
This is really important. All muscles need hormones. Think of bodybuilders and testosterone. Think of old ladies who the wind blows and they break a hip, right? And they fall over and they have sarcopenia or they have very thin muscles. Hormones are really important for muscle health. That is probably a combination of hormones, but we know testosterone plays a very important role in muscle health. I see a lot with patients, if we put them on testosterone, it actually not only helps their pain with sex, but it helps their stress incontinence because the pelvic floor muscles tighten. We need to write about this, by the way. Mild stress incontinence is made better with systemic testosterone. I’m officially comfortable saying that out loud. Hormones matter for the tissue, but they can also matter for the strength of the muscle and your ability to strengthen pelvic floor muscles.
I’ll ask you, I mean, you have done this for so many years, Dr. Stein, what is your experience with the patients who are not on hormones versus those who are? And then what you see as they start hormone therapy, whether it’s local hormone therapy just for the tissue versus whole body hormone therapy for their menopause symptoms.
Dr. Amy Stein, DPT
I have to say I’ve had more experience with the local and then learning from you the estrogen testosterone cream. I’d be interested after I answer this question to hear more about the systemic effects of the testosterone. But it does, to me it makes sense from a muscle point of view and then with the physical therapy, it definitely helps with the floor rehabilitation of the muscle and trying to get them stronger for sure. So there definitely is a positive effect of doing the two at the same time.
Dr. Rachel Rubin, MD
I would say that you and some of your colleagues in this space who’ve been around a little longer than some of the newbies, I don’t think they know how pioneering it was for you all to make that connection between the hormones. I remember even when I was in fellowship, which was 2016, so it wasn’t that long ago, that it was unheard of for a pelvic floor physical therapist to think about hormones, to talk about hormones, to recommend hormones. I remember doing courses with some of your colleagues. It was like we were crazy people really trying to educate the pelvic floor physical therapists and now, thank goodness, you all became leaders in the space, and it has completely transformed in just a few years, which is so amazing to see.
Dr. Amy Stein, DPT
Yeah it’s been wonderful to see, but we have so far to go still, you know. Can you explain briefly, the difference between estrogen, testosterone, cream versus oral medication, but also maybe just give a brief on what exactly is estrogen, testosterone cream, because most of the OBGYNs here in New York, they still mostly just prescribe estrogen.
Dr. Rachel Rubin, MD
We have a lot of work to do in this space because we’ve known about this for a long time, but there’s not enough. We’re not loud enough about this. There’s data, there’s research, there’s published papers, but if nobody reads your published papers, it really doesn’t get you very far. I think we need to go a step back. You have hormone receptors in all of your body. You have estrogen receptors in your brain, you have estrogen receptors in your skin, you have testosterone receptors throughout your body, and so it’s everywhere. We know that the vulva, the genitals are very hormone sensitive, both to estrogen and testosterone. And so what happens when there’s an altered hormone state? Now that might be birth control pills, which lower testosterone in everybody, because birth control essentially shuts down your ovaries, so you’re not making testosterone and it often adds back fake estrogen and fake progestin, but it’s not adding back testosterone. Not having testosterone around really depletes the tissue of what it wants and so it gets dry, it gets irritated, it gets uncomfortable, it throws off the pH.
What we see clinically, Dr. Stein and I, is women come in saying sex hurts. We’re getting urinary tract infections, but the cultures are negative or the cultures are positive. I can’t put tampons in anymore. Everything’s uncomfortable. What we see on exam is inside the labia minora, inside this tissue right here, it is like raw hot chili peppers to the touch. That tissue is called the vulvar vestibule and it’s the most common reason we see people have pain with sex of any age. It happens commonly in menopause. It happens commonly in women on birth control pills and it happens commonly in women who are breastfeeding and postpartum. What we have found is it’s often a hormone, not always, but often a hormonal problem, right? It is because they are not getting the proper hormones in this tissue. For someone on oral birth control pills, we tend to get them off oral birth control pills. We like hormonal IUDs because they don’t stop ovulation. We like to add back hormones. A mother who is breastfeeding or a menopausal woman, we like to add back hormones and you can add back hormones locally to the tissue without affecting the whole body. We often do whole body hormones for hot flashes and night sweats and osteoporosis prevention. Those are awesome for many people. They actually aren’t always enough or often enough to heal the local tissue at the opening. What we have found, there are a number of tools that we use to try to replenish the tissue with hormones. Vaginal estrogen is more commonly talked about and more comfortable in this space and it works for a lot of people. There’s a few different forms. There’s creams, there’s inserts, there’s rings, there’s different forms of vaginal estrogen. There are some studies to show that it actually can help with that vulvar vestibule pain.
But what research of some of my colleagues have shown over many decades now is that tissue is actually really sensitive to testosterone and so estrogen is not always enough. Unfortunately, we don’t have an FDA approved product, which is what it makes it difficult to teach your general OBGYN. We’ve had to learn and extrapolate. It’s one of the few areas where I compound products. I don’t like compounded products for whole body hormones. I only use compounded products when I have to, and here’s a situation where I kind of have to. We take a minuscule dose of estrogen, like in an estrogen vaginal cream, a 0 .01% cream and we take a minuscule amount of testosterone. We use a 0 .1% testosterone. Now, when I give women testosterone for their libidos, and I do that a lot, people, I do a lot of higher dose testosterone for libido, it’s 1% testosterone. This, what we use in this compounded cream for this local area is 0 .1% testosterone. So it’s 10 times less. So it’s not gonna help with your libido, that’s a whole other product that we use. But it will help locally at this tissue heal it. And again, Amy can tell us what she sees in her pelvic floor world. She sees magic, which is why she’s such a believer.
We use a local compounding pharmacy. It’s funny, the guy has just been with us for so long that we know his formula, he knows us, we know him. I think he makes witches brew vats of it. I think everyone in DC puts this on their genitals. That’s how I picture it. It’s like a cauldron and he just gets the exact dose right. A pinch of this, a pinch of that. He puts it in these twisty things and you twist it and you get a little gel here. You put it on your finger and you rub it in. Again, I don’t like compounded clicky products when you’re treating your hot flashes. I like FDA approved products. but here is one place where we actually don’t have an FDA approved product. I know I went long winded there, but I think it’s important that people understand that hormones are not all the same things. Your birth control pill is not the same as your menopause hormones. The menopause hormones are lots of different hormones in different ways to deliver it. Then there are local hormones which don’t go through the whole body. They all have different risks. They all have different effects. And they’re all essentially important when we’re having these conversations about menopause.
Dr. Amy Stein, DPT
Yes, and it’s so important to have someone like you so that they get help figure out what would be best for the patient. And then from a physical therapy perspective with regard to hormonal mediated vestibulodynia, what we see is that the patient can basically more or less grip the muscles or contract the muscles because of the discomfort and then that becomes like a habit and then they have two issues going on which they need to see Dr. Rubin for the hormone like the cream and then also the tissue problem and then the muscle problem. And the muscle problem is where we compliment each other so well on healing these patients, because we can heal them. So to more questions, how do hormonal imbalances like PCOS, thyroid issues, how do they impact sexual and pelvic health?
Dr. Rachel Rubin, MD
Yeah, I mean, I think there is a lot we don’t know and that’s why, again, it’s really important to look at the whole person, look at the whole person, and then also work with different clinicians to really try to optimize whatever it is. First of all, I mean, you wrote a book on endometriosis, so you know how insane it is in 2024, how little we know about women’s health conditions. I’m a urologist, I’m not a gynecologist and when I start probing questions about PCOS and I get these bullshit answers from people like, well, we don’t really know this and we don’t really know that. Do we know anything? Can we definitively say anything about PCOS? I don’t know that we can. We’ve blamed testosterone a lot as being the problem. But I’m not sure that that is actually the true story. I think there’s a lot of insulin resistance that we’re starting to understand. I think everyone with PCOS doesn’t all have PCOS and doesn’t all have the same problem. I think unfortunately we have had decades now where our only solution is birth control pills. It’s literally a brain drain because it has stopped research into helping find other treatments, other therapies, other things that can help people using their natural hormones that are happening or more natural hormones. Again, when you play with hormones, there are consequences. You of course can have effects on your sexual health if you have PCOS or endometriosis or premenstrual dysphoric disorder (PMDD) or any of those things. Unfortunately it’s not a one size fits all of everyone with PCOS take this pill and they will be sexually happy. You have to really work with someone who knows you and knows what’s going on in your body to the best that anybody understands it and is willing to try different things with you.
Dr. Amy Stein, DPT
Yeah, yeah, I agree. So you explained very well before about like local symptoms and the vestibule that patients may feel.if they have a hormonal imbalance like the cayenne pepper type feeling, you could have itching, rawness type feeling, and what to do in those scenarios.
The Benefits and Risks of Hormone Therapy for Menopause
Dr. Amy Stein, DPT
What are some other symptoms, probably more like systemic symptoms that you would identify as having a hormonal imbalance or contribute?
Dr. Rachel Rubin, MD
This is where we have a new term that we’ve started to use, which I think is really cool. There was a paper published recently this year called NFLM, Not Feeling Like Myself. And I think it just captures it so beautifully because every woman in their late 30s and 40s, I literally had my best friend from middle school call me just before we did this podcast, saying, “What in the actual hell is happening to me? I’m a very smart woman, and I don’t know what it means to lift weights, eat protein, get sleep, and like, what the hell is happening in my body?”
And that is what’s happening. You have all these smart, really capable people, and they’re falling apart. It’s not their fault. They can’t yoga their way out of it, and they can’t pay their way out of it for an easy fix or one pill. It’s about understanding the symptoms, and they can be so variable, and everyone experiences this differently. So it could be dry eye, changes in your hair, skin, and nails. It can be your sleep going to hell. It can be a frozen shoulder or, you know, plantar fasciitis, which we’re now terming the musculoskeletal symptoms of menopause or the syndrome of menopause. We see a lot of dryness. We see urinary tract infections pop up around now. Pain with sex starts to happen for some people. There are a gazillion symptoms because you have hormone receptors all over your body.
But we don’t teach all doctors about hormone receptors and how hormones are important for the body. So it’s a nightmare because our patients are going to 12 doctors. You go to your cardiologist for your heart palpitations, you go to your neurologist for your headaches, you go to your orthopedist for your frozen shoulder, and none of them were taught about perimenopause. They literally will say to you, well, this happens sometimes in this age group, and we don’t really understand it. So here are some anti-inflammatories, or here’s a big workup that shows that you’re fine, lady. Just suck it up.
It’s kind of a nightmare we’re living in because we don’t teach doctors about menopause. Literally, the studies show that less than six percent of doctors, and this includes OBGYNs, get any training whatsoever in menopause. So, welcome to the nightmare. Glad to have you. You actually have to find your information from Instagram, from podcasts, and from doctors who deeply care about these issues. You have to educate yourself because you have to learn how to advocate for yourself.
Dr. Amy Stein, DPT
Yes, and you have been a pioneer with the ISSWSH crew and many others with the term GSM, genitourinary syndrome of menopause. You’ve taught me a lot about that. So we’re on a track, but we still have a long way to go.
Dr. Rachel Rubin, MD
It is a problem because many of us are in this echo chamber. We all follow each other, and we’re like, everyone knows this. Then you step out of the echo chamber and realize nobody knows it. My colleague, who is now seeing patients in our LA office, Ashley Winter, is like Twitter’s favorite urologist. She talks all day, every day, about vaginal estrogen and its benefits in preventing urinary tract infections and helping with pain during sex. Guys, we’ve had vaginal estrogen since the 1970s. It’s been around. It works great. It’s as good as Viagra for women, yet it’s not being marketed or prescribed appropriately. The simple thing actually turns out to be the most important. We just published a study that showed if people on Medicare used vaginal estrogen appropriately, like they should be doing, we would save Medicare between $6 and $22 billion dollars a year. Billion.
Dr. Amy Stein, DPT
Wow. From what specifically though? Because of UTI and incontinence?
Dr. Rachel Rubin, MD
UTI prevention. I don’t even think we used incontinence. That would probably triple the billion dollars. But for UTI, for hospitalizations, for urosepsis, for urgent care visits, prescriptions for antibiotics, antibiotic resistance, $6 to $22 billion. If we added incontinence in there, I can’t even imagine a number that high.
Dr. Amy Stein, DPT
Yeah, that’s crazy.
The Impact of Pelvic Floor Function on Sexual Response
Dr. Amy Stein, DPT
Speaking of the incontinence part, how do you describe to patients how pelvic floor function or dysfunction helps with sexual response?
Dr. Rachel Rubin, MD
It’s so important, right? The pelvis is a sexual area, the whole area, right? The clitoris, the vagina, this is all sexual anatomy. And as it changes, if you have a watermelon come out of your vagina or your abdomen, it’s going to change your sexual anatomy. If the vagina or uterus prolapses or falls down, it may change your sexual anatomy. If you have hormone changes, it’s obviously going to change your pleasure and your sexual anatomy. When you leak all the time, when you cough, laugh, or sneeze, or when you feel urgency, that doesn’t feel very sexy for most people. That can affect your confidence in your sexual health.
I’m a big believer that if something is bothering you or affecting you, it is a problem, and it deserves a solution. We have a lot more doctors who can take care of prolapse and incontinence than we do doctors who take care of sexual health. But when you address prolapse and incontinence, it can help with sexual health, of course. There is often more to it than that, which is why we are teaching and educating doctors to care about more than just those things. But it is a really good beginning. No woman should be suffering with incontinence and prolapse. There is so much we can do to help.
The Benefits and Risks of Hormone Therapy
Dr. Amy Stein, DPT
Yes, I agree 100%. What would be some of the risks, if there are risks, with hormonal therapy?
Dr. Rachel Rubin, MD
There is a difference between hormones used locally for the vagina to prevent urinary tract infections, and those really don’t have risk. You may see an occasional yeast infection when you start the therapy, and that’s because the vagina is getting more acidic. As the microbiome shifts, sometimes you get a yeast infection, you treat it, you keep going, and it goes away. Sometimes people do not like a certain modality. We have patients who say, I can’t take vaginal estrogen. I tried it, and it didn’t work. Maybe the cream was irritating and it didn’t work for you, so why don’t we try an insert? Why don’t we try a different product? You have to find the right modality and the right product. There are inserts, creams, rings, and different options.
Now, systemic or whole-body hormone therapy gets a little more nuanced because there are a lot of different ways to take it. You could take a pill by mouth, use a patch, or apply a gel. A lot of patients on the internet talk about pellets, which we don’t do, but many people offer and charge way too much money for. They are not regulated by the FDA. There are many different ways to do whole-body hormone therapy, which means there are a lot of different risks that you need to understand. That is why you have to work with a hormone specialist, like a menopause specialist. If your doctor is only offering you one type of hormone therapy at a high price, that is not the right person.
You need someone who says, here are the options. There are pills, rings, creams, and injections. There are different choices, and here is what is right for you. A pill of estrogen does have an increased risk of blood clots, but a patch of estrogen does not show a significant increase in blood clots. We do a lot of counseling and educating patients. We also spend a long time talking about how we don’t know everything. There are a lot of things we still do not understand. Another part of the conversation that no one talks about is the risk of not taking hormone therapy. If you choose not to take hormone therapy in menopause, you may be at an increased risk of osteoporosis or heart disease. Not doing anything has significant consequences.
We do not really talk to women about that, nor do we often give women the choice to say, here is what we know, here is what we don’t know. What do you want to do with your body? How do you want to live today? How do you want to live in five years and twenty years? How do you want to age?
Because I’ll tell you, I want to be a woman at 90 who can take a suitcase and put it in the overhead bin when I’m going to Hawaii. That is what I want if I am going to work this hard now. I don’t want to be in a nursing home with dementia, living out the years trying to remember the podcast I was on in 2024, right?
Dr. Amy Stein, DPT
That’s hilarious. I love it. I feel the same way. What about our pregnancy population and our postpartum population and those that are breastfeeding? They’re suffering too. What are some of your suggestions for them? Because they fear any type of hormonal therapy.
Dr. Rachel Rubin, MD
Yeah. So we’re doing a big push right now for that population. We just coined a term, GSL, or genitourinary syndrome of lactation. We just published a paper on it, and we have a whole team of students actively working on a research project, looking at it from multiple angles. What I told our students, and we call ourselves the sexual medicine research team, is that it’s not enough for you to publish papers. You have to publish the papers and do the research, but as you’re thinking about that, you also need to be doing outreach campaigns, advocacy campaigns, and getting handouts in doctor’s offices. You need to think globally about all these problems.
We’re working on it, but really, what it shows is that when you’re breastfeeding, you’re menopausal. Right? Your hormones are essentially the same as menopause, but it’s not forever, usually. For some people, it might last two or three years. It can come with low libido, vaginal dryness, and urinary tract infections. The data supports the use of vaginal hormones in this population. There’s actually no data point on earth to show harm to milk supply, systemic blood levels, the baby, or the mom. We’ve got that data. The issue is how that data is disseminated, how it’s used, and the fact that no one is talking about it. No one is telling their patients, only use this if you really need it. That is insane.
At the six-week visit, every gynecologist talks about birth control. Birth control contains giant amounts of hormones, and they literally say, you can take this, it’s safe, it won’t affect your milk supply, it won’t affect your ability to take care of your baby. Here you go. Here’s the prescription at six weeks. But vaginal estrogen, which doesn’t enter your bloodstream and doesn’t affect you at all, is a minuscule dose, and no one even brings it up. You can’t make this stuff up. It’s outrageous.
Dr. Amy Stein, DPT
I really appreciate you encouraging the students and the residents to really get out there and advocate. That’s why we have you on here right now, because we need more people like you advocating, spreading the word. These poor pregnant postpartum women, they’re feeling like it’s all in their head and they’re crazy and you know, it’s all because they can’t sleep and whatever else because of the baby. But part of the not being able to sleep is this hormone dysregulation as well. So we appreciate all that you’re doing to spread.
Dr. Rachel Rubin, MD
We have a lot of work to do and it can’t just be me, which is why we have to be loud and bring others up with us.
Supporting Hormonal Levels and Sexual Health through Diet, Exercise, and Stress Management
Dr. Amy Stein, DPT
Yes, agreed. Let’s get on to more of how you can support hormonal therapy or if those that choose not to do hormonal therapy through diet, exercise, stress management and how that can affect hormonal levels, but also sexual health.
Dr. Rachel Rubin, MD
It’s really important that people take care of themselves. Self-care is not taking a bubble bath and getting a massage once a year. That is very pathetic if that’s your only form of self-care. What is important for self-care is educating yourself. That’s probably the most important thing, knowing that your body deserves this. That you as a human deserve the best evidence that exists on how to live as long and as healthy as possible, because just living the numbers is not living your life. My mother-in-law, who’s in her mid-80s, said to my husband on the phone last night, you really got to start exercising because you don’t want to be like me, who never exercised enough, and now I’m feeling it, right? So look at the older people around you and ask yourself, do I want that? Do I want Betty White, or do I want Dolly Parton at the Super Bowl? Is that how I want to age? And what’s going to get you there, because it’s going to take self-care to get you there.
Self-care means getting the right medicines and hormones in your body to keep you as strong as possible. It means lifting weights so you can build muscle and prevent your bones from breaking down. It means fueling your body with nutritious food that builds protein, builds muscle, and is real food. It means not starving yourself just to fit into a bikini but feeding yourself healthy food so you can lift that suitcase into the overhead compartment at 90. And sleep. We have to get you sleeping, and sometimes you need progesterone to sleep enough because if you don’t sleep enough, you will die earlier. You will not have a brain that is capable of healthy living. That’s the change in self-care. It’s no longer about Botox in your forehead or doing a juice cleanse. It becomes about asking yourself, how do I want to invest in my body, my mental health, my physical health, my nutrition, and my hormones to live life to the fullest? I think that’s the paradigm shift we need to start going after.
Dr. Amy Stein, DPT
Yeah, and it also doesn’t have to be expensive either. It could mean just going out for a walk every day, but really trying to get your heart rate up if you’re not feeling up to it. Definitely always listen to your body. If you’re not feeling up to it, take a slower walk or do a little yoga at home. There’s definitely free yoga YouTubes these days.
Dr. Rachel Rubin, MD
In the era of YouTube, it’s no longer, I can’t do this because I don’t have money, right? Lifting soup cans to build muscle is better than doing nothing at all. Luckily, people have podcasts now, so you can put us in your earbuds and go for a walk around your neighborhood, right? These are the things you can do. And it’s hard. I know it’s hard. For me, I don’t have an hour in the day to exercise. I have small kids, I have a busy, growing practice, so I made a commitment to myself. I’m gonna do 10 to 20 minutes, two to three days a week. It’s all I can do right now, but I’ve now done it for 89 weeks in a row, and it’s good, right? It’s 10 to 20 minutes, two or three days a week. I’m not running a marathon, people. But because I’ve done it so consistently, I now see myself thinking, I want to eat more protein. I feel better when I do this. Now, on the weekends, I actually want to do a 30-minute workout because I enjoy the way I feel when I do this. It gets a little addicting in that way, but you don’t have to be intense about it. You don’t have to be a bodybuilder or a rich person to do it.
Dr. Amy Stein, DPT
Yeah, there’s so much more focus on functional training now and basically using your own body weight to exercise. Definitely search on YouTube, how to use your own body weight to exercise. How would you say stress impacts hormonal levels and sexual health?
Dr. Rachel Rubin, MD
Not having hormones in your body can really increase cortisol and inflammation and all of that. We’re only just starting to understand all of these things. And so for me, I always want to prevent problems from happening as opposed to seeing people when they’re at their worst. But we’ll see people when they’re at their worst.
You know, it’s funny, I have a patient I’m thinking about right now. She worked at Google. She was at the top of her game and she got COVID. She sort of went on this whole long COVID journey. I have POTS. I have long COVID. She came to me a shell of a person and she was 47 or 48. We listened and I talked to her and I heard her. I validated her and we got all of her medical history. I said, I totally understand and what if we help supplement you and support you with hormones because the hormones are just going crazy in your body right now. That’s going to help your POTS. It’s going to help your long COVID. It’s gonna help support and put some gas in your gas tank.
And she’s like, I’m afraid of hormones. My mother had X, Y, and Z. I can’t do X, Y, and Z. We again, educated as much as possible, met her where she was. I just talked to her a few weeks ago and she is back at work. She literally said to me, I couldn’t believe this. We had a virtual call and she said, I feel great, Dr. Rubin. I just need my refills. She said, I just started dating someone. I love sex again. I’m so happy. She didn’t mention POTS, she didn’t mention long COVID, she didn’t mention how tired she was. She looked like a million bucks.
I gave her estrogen, progesterone, and testosterone. I gave her three things. She doesn’t spend very much money on them. The testosterone is nine dollars a month, the estrogen is covered by her insurance, and the progesterone is covered by her insurance. She was a new person. I said to her, no one believes me when I talk about these patients. no one believes it. She said, Dr. Rubin, I didn’t believe you. I can’t believe how good I feel. Then she said the magic words. She said, I feel like me. That was just the best, right? So much of long COVID is the inflammation happening because your body is so hungry for healing and doesn’t have the right hormones to help you heal. We need to be doing more research on the intersection between perimenopause, long COVID, and all these things. We’ve got a lot of work to do.
Ongoing Research in Women’s Health: Addressing Knowledge Gaps
Dr. Amy Stein, DPT
Yeah, we do. And speaking of a lot of work, you have been instrumental in research in these areas of women’s health, sexual health, and pelvic health. What are you working on these days with regard to up and coming research?
Dr. Rachel Rubin, MD
Yeah, we’re doing some work in genitourinary syndrome of lactation. We’ve got a nice project going right now about orgasm and how doctors have no idea how to talk to patients about it. There’s no framework, no proper questioning, and no questionnaires that actually work. How are we supposed to gather data on orgasm when no one’s even asking the same questions? We have data on some rare sexual health conditions that we’re researching, including something called post-orgasmic illness syndrome. We actually have a ton of projects going on, and it’s so fun to have this research team.
One of my favorite projects we’re working on right now is on the labia minora. When you’re a baby, you don’t have them. You grow them in puberty, and you lose them in menopause. That’s all we know. We have no idea if it’s estrogen, if it’s testosterone, if you can grow them back, or if everyone loses them the same way. No one has even begun digging into this. Literally, all the research we have is about people wanting to cut off their labia to look more like porn stars, which, don’t get me started. There is such a lack of research on this part of the body, so we’re trying to change all that.
There’s so much work to do in this space, and I’ve been able to train a doctor who’s joining us in September. She has appointments available if anyone needs them. We have another doctor who’s joined us, and we have Dr. Winter out in LA. My dream is to start a fellowship where I can train doctors at the highest level to do this because you can’t just take a weekend course and be an expert in this. You have to be obsessed with it. You have to want to do it and learn.
I actually think the definition of an expert is someone who’s willing to say, we don’t know. Someone who asks, what if we try X, Y? Here’s what we do know, but we don’t know X, Y, and Z. Those are the doctors you want to surround yourself with, the ones who are curious, the ones who know what we know but also know what we don’t know, and who are willing to try new things while pushing the science forward.
Dr. Amy Stein, DPT
Yeah, I would love to see research, and I’m not as research savvy as you are by any means, but research on if we could do hormones with pelvic floor physical therapy and how that improves the orgasm.
Dr. Rachel Rubin, MD
I do too, I absolutely want to do that research.
Finding Support and Reliable Information: Resources for Women’s Health
Dr. Amy Stein, DPT
Yes. What are some other resources or support networks that women can find more of this information because as we know, there’s a lot of misinformation out there. What do you recommend?
Dr. Rachel Rubin, MD
Yeah, so for anyone with pelvic pain, I’m obsessed with the organization called Tight Lipped. It’s a patient advocacy organization, and they’re doing incredible grassroots work, going door to door to residency programs to teach doctors how to examine and diagnose pelvic pain conditions. I love what they do. If you’re a patient and you want to feel like your voice is heard, get involved because they need your help.
If you need to find a clinician, ISSWSH.org is a great way to find a provider for sexual health. If you need a menopause provider, menopause.org is a great resource. There are doctors like me who are on both websites, and that’s really important because you see a lot of the intersection between the two.
For male pelvic health, I’m also on the Sexual Medicine Society of North America website, SMSNA.org, where you can find providers who specialize in male sexual health.
Dr. Amy Stein, DPT
Amazing. If you’re looking for a pelvic floor physical therapist, there’s the APTA, the American Physical Therapy Association. I believe ISSWSH that you mentioned earlier has physical therapists on it as well, as well as I think Pelvic Guru has physical therapists, pelvic floor physical therapists specifically. This has been amazing. Can you tell our listeners how they can find you and where you are located and do you do virtual?
Dr. Rachel Rubin, MD
We have a great newsletter on RachelRubinMD.com. I would love for you to sign up. You can find us on social media @DrRachelRubin. And our LA office is taking new patients. We’re taking new patients in our DC area office. We often like people to come in and really experience what it means to sit with someone and really get a deep in-depth visit. We try not to do the first visit as virtual, although again, we’re actually finding innovative and new ways to treat more people and to help people. That’s where the newsletter becomes really helpful because I’m really trying to do more and the more that we can do, the better. So if you’re in California, please reach out. If you’re in or willing to travel to California or the DC area, please reach out. And follow along because you deserve this type of level of care. Everybody does.
Dr. Amy Stein, DPT
Yes, I agree. We need more of you in New York City, by the way, if you ever want to branch out, I know we have Andrew Goldstein, but he’s just one person. New York’s huge. Thank you so much for this wonderful podcast. I hope to see you soon at ISSWSH. This has been amazing. I look forward to seeing you soon. Thank you.
Dr. Rachel Rubin, MD
Thank you so much for having me.
