Women's sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.

**Peter Attia, MD** (0:11)
Hey everyone, welcome to the Drive podcast. I'm your host, Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. If you want to learn more about the benefits of our premium membership, head over to peterattiamd.com/subscribe. My guest this week is Dr. Rachel Rubin. Rachel is a board certified urologist and one of the nation's leading experts in sexual health. She is among a select group of physicians with fellowship training in sexual health for both men and women, bringing a rare and deeply informed perspective to her clinical work. In our conversation today, we focus on women's sexual health. We discuss why sexual medicine, particularly for women, remains so neglected in traditional healthcare. The critical difference in how men and women experience hormone decline with age, the physiology of the menstrual cycle, including the role of estrogen, progesterone, FSH, and LH and Y perimenopause is characterized by extreme hormone fluctuations. The risks of menopause beyond just symptoms like hot flashes, including the risk of osteoporosis, cardiovascular disease, dementia, and recurrent UTIs. The long-standing controversy around HRT and how a single study, the Women's Health Initiative study, led to decades of fear-based medicine and an entire generation of women, by my calculation more than 20 million, deprived of the benefits of HRT. How to use estrogen, progesterone, and testosterone therapy for women, including dosing, delivery method such as oral transdermal vaginal, and why personalized care is essential. The overlooked role of testosterone in women's health both before and after menopause. The benefits of local vaginal hormonal therapy, a safe, inexpensive, and underutilized treatment that prevents urinary tract infections, improves sexual function, and dramatically enhances quality of life in postmenopausal women. This is a podcast in which I learned a lot, even though I like to think I know quite a bit about this already, but Rachel's expertise here is second to none, and I was feverishly taking notes throughout, and obviously can't wait to implement many of the things I learned into my own clinical practice. So without further delay, please enjoy my conversation with Dr. Rachel Rubin.
Rachel, thank you so much for making the trip out to Austin. I have been looking forward to this episode for a while, and I'm willing to go on record predicting that this will be a very popular episode given the nature of our discussion.

**Rachel Rubin, MD** (3:21)
I am so thrilled to be here. I have been nervous for quite a long time, but I'm super happy to be here.

**Peter Attia, MD** (3:26)
I almost don't know where to begin, but it might not be a bad idea to just give people a little bit of a sense of your background. You are a urologist by training, and maybe help us understand how your training in urology led you to what you're doing today, because most urologists wouldn't be doing exactly what you're doing. When we think of urology, we think about prostates, we think about kidneys, we think about bladders.

**Rachel Rubin, MD** (3:52)
Yes, but what you forget, Peter, is that urologists are ultimately the quality of life doctors. We deal with urination problems and we deal with sexual medicine, right? No one cares about erections and orgasm and libido, quite the way that a urologist cares about. And when we're board certified, actually, it's not a gender thing. We're not penis doctors only. We're board certified to take care of everybody's genital and urinary tracts. Unfortunately, society has led us to know a lot more about the men's sexual health and men's genitals than female genitals. And so my background, I trained in urology really because I was interested in women's health but I also was interested in sexual health, sexual medicine. And I didn't like delivering babies. I didn't like OBGYN. It just didn't fit well with my personality. And what I love about urology is that we can see everybody and we can really dive deep on quality of life issues. And the magic of urology is also that you really get to know your patients. It's not like when you did surgery, you take out someone's appendix and you never see them again. Maybe you do one post-op visit. Urologists have deep relationships. We're both surgeons, but we actually care about the medical side of these quality of life issues. And so as I was going through medical school, I really realized that talking about sexual health, quality of life issues, that was fun for me. I was good at that. And in medicine, you gravitate towards what is easy, not what is hard. And so it's just been a joy.