The Most Important Conversation You’ll Ever Hear About Women’s Health | Dr. Rachel Rubin

KEYPOINTS

• 01

  Most 'down there' problems trace back to changing hormones

  Dr. Rachel Rubin, a urologist and sexual medicine specialist in Washington, DC, says recurrent UTIs, urgency, leaking, waking up at night to pee, dryness, burning, painful sex and low libido are mostly driven by hormonal shifts that change the tissue and the microbiome of the vagina and bladder. Women are routinely told it's aging, stress or 'all in your head.' She says that whenever you catch yourself thinking 'this is just how it is,' it's worth asking a clinician.

• 02

  Hormones shift throughout a woman's life, not just at menopause

  The ovaries make estrogen, progesterone and testosterone. In a typical cycle, estrogen sits around 50 during your period and peaks at ovulation (150–300). Progesterone rises in the second half, and its drop triggers your period. Testosterone likely peaks at ovulation, driving libido. In perimenopause, the cycle swings like puberty in reverse, with cycles going from 28 days to 35 to 18.

• 03

  Many common medications and life stages lower these hormones

  Birth control pills, spironolactone for acne, breastfeeding, breast-cancer hormone therapy, perimenopause and menopause can all raise the risk of UTIs and pain with sex, she says. One patient that week had urinary pain from birth control pills plus spironolactone. While breastfeeding, she says, 'you're in menopause' hormonally, a condition she calls genitourinary syndrome of lactation.

• 04

  Vaginal hormones cut UTIs by more than half, and she says we've known for decades

  Rubin says vaginal estrogen or vaginal DHEA prevents urinary tract infections by more than half. The evidence dates to the 1990s and the products to the 1970s, yet few women hear about it. Her explanation: 'the two dirtiest words in the English language are vagina and estrogen,' and other specialties leave women's health to busy gynecologists.

• 05

  Vaginal hormones are a different category from whole-body HRT

  They're micro-dosed and stay local. In a 70-year-old woman with essentially zero estrogen, she says, levels may blip to about 20 for a couple of hours and then return to zero. A typical man's estrogen is about 25. That's why she calls them safe even for people who fear systemic hormones, and suitable for life, 'for your great-grandmother in the nursing home.'

• 06

  Being on HRT doesn't mean your vaginal tissue is covered

  Her favorite statement in the 2025 genitourinary syndrome of menopause guidelines (from the American Urological Association, which she spent about seven years advocating for) is number 11: people on systemic hormone therapy should still be screened for these symptoms and offered vaginal hormones.

• 07

  Four buckets of hormone care

  Whole-body estrogen (patch, pill, gel or pellet) treats hot flashes and night sweats and protects bones. Whole-body progesterone protects the uterine lining if you have a uterus and may help sleep and mood. Whole-body testosterone mostly has data for libido. Vaginal hormones are separate from the other three. You don't need every bucket.

• 08

  Women have no FDA-approved testosterone

  Men have about 27 options. Rubin says a roughly billion-dollar study showed five years of efficacy and safety for women's libido. Around the time of the 2002 Women's Health Initiative scare, the FDA asked for five more years and another study, and the product died. It's approved in Australia, New Zealand, South Africa and England.

• 09

  The two biggest causes of painful sex are hormones and tight pelvic-floor muscles

  Hormonal changes cause a 'sunburn-like' pain, and the body guards against it by tightening. Fix the hormones and the muscles may still be clenched, so both often need treatment. She insists sex shouldn't hurt, and that advice like 'have a glass of wine' or 'just have more of it' is dismissive.

• 10

  The system, not just your doctor, is the problem

  Appointments last about 10 minutes, and vaginal irritation won't make a doctor's top 27 topics. Women were understudied for decades, so research is about 30 years behind. Her advice is to be the CEO of your own care team, come prepared, and be kind to clinicians, who also want more time.