Dr. Rachel Rubin on Vaginal Hormones, UTIs, Testosterone and Women's Sexual Health

High-Level Overview

Mel Robbins interviews Dr. Rachel Rubin, a board-certified urologist and sexual medicine specialist, in what Robbins calls the most important women's health episode her show has done. Rubin's central argument is that a large share of the urinary and sexual problems women are told to live with (recurrent urinary tract infections, urgency, frequency, leaking, dryness, painful sex, fading libido and orgasm) have a hormonal basis, and that inexpensive, long-established treatments exist but are rarely offered because doctors were never trained in them. She spends most of the hour on low-dose vaginal hormones, which she says cut urinary tract infections by more than half, then moves through whole-body hormone therapy, testosterone for women, a little-studied condition called clitoral adhesions, basic vulvar anatomy and the causes of pain with sex.

The tone is energetic, frank and often funny, with Rubin emptying a bag of models and prescriptions onto the table and Robbins reacting with open astonishment and her own medical history. It is also a single-expert advocacy conversation: Rubin presents her positions with great confidence and the host does not challenge them, though Rubin herself notes where data are thin. The episode moves from why women's sexual health is neglected, through the hormone life cycle, into specific treatments and costs, and ends with anatomy and practical advice for getting care.

The Discussion Explores:

• Why neither gynecologists nor most other doctors are trained in women's sexual medicine
• How hormone levels shift through puberty, the menstrual cycle, pregnancy, breastfeeding, the thirties and menopause
• Genitourinary syndrome of menopause (GSM) and why Rubin says it can affect women of any age
• Vaginal estrogen and DHEA: forms, cost, how they are used, and the removal of the FDA boxed warning
• The legacy of the 2002 Women's Health Initiative and the four "buckets" of hormone therapy
• Testosterone for women: what it is said to help, how Rubin prescribes it, and its lack of FDA approval
• Clitoral adhesions, vulvar anatomy and the main causes of painful sex
• How to use a ten-minute appointment and build a care team

Deep Dive into Main Ideas

A gap in medical training

Rubin begins by explaining what a urologist is: a doctor of the kidneys, bladder and genitals of everyone, not only men. The common assumption that gynecologists handle everything for women is mistaken, she says, because gynecology training covers reproductive health and gynecologic cancers but not sexual medicine. She states that the word clitoris does not appear in what a gynecologist must know to finish training. Urology has long treated men's sexual function and testosterone, while women's sexual health has been ignored.

The result, in her telling, is not bad doctors but untaught ones, and she wishes more would simply say they did not learn this. Instead, patients report being told to drink a glass of wine, read an erotic novel, have more sex to fix painful sex, or accept that this part of life is over. She urges women to notice whenever they tell themselves that something is just aging or just stress: waking more at night to urinate, drier or more painful sex, orgasms that are slower or missing, not feeling like oneself. These, she says, have a biological basis alongside any psychological one. In her words, "Low libido is a medical condition if you are bothered by it".

The hormone life cycle

Rubin insists hormones are neither good nor bad. The ovaries make estrogen, progesterone and testosterone. In a regular cycle she describes estrogen at around 50 during a period, rising to perhaps 150 to 300 at ovulation, with progesterone dominating the second half until it drops and the lining sheds. In pregnancy she says estrogen is about 3,000 for nine months and then crashes to zero at birth; a woman who is breastfeeding and has not had her period return is, in her description, in a temporary menopause with all its symptoms, including hot flashes, brain fog, dryness, leaking and infections.

Around the thirties, she says, testosterone begins to fall with age, or earlier if it has been suppressed by birth control pills or the acne drug spironolactone, with consequences she lists as lower libido, more infections and more pain with sex. Perimenopause then resembles puberty in reverse, with estrogen swinging wildly, until, as she puts it, "menopause is a castration event" in which the hormones switch off. Her refrain throughout is "when you play with hormones, there are consequences", sometimes good and sometimes bad.

GSM and the case for vaginal hormones

The condition at the centre of the episode is genitourinary syndrome of menopause: what happens to the vagina, vulva, bladder and urethra when hormones change. Rubin says the name is misleading, since the same changes can occur on birth control pills, during breastfeeding and on endocrine therapy for breast cancer. These tissues are full of estrogen and testosterone receptors, and "like a plant needing water" they need hormones. Without them the tissue thins and dries, the vagina loses its protective acidity, harmful bacteria grow, and the bladder becomes irritable. Sex, she adds, can further raise pH and abrade fragile tissue, so some of what feels like an infection is irritation that antibiotics will not fix.

Her claim is that tiny doses of hormone placed in the vagina restore the pH and microbiome and prevent urinary tract infections by more than half, while also easing urgency, frequency, leakage and painful sex. She says products have existed since the 1970s and supporting evidence since the 1990s, that her research group estimated Medicare savings of $6 to $22 billion a year, and that the American Urological Association published guidelines on GSM in 2025 after years of advocacy. Her explanation for why women have not heard this: "the two dirtiest words in the English language are vagina and estrogen". She cites a recent JAMA paper from a Stanford colleague finding that among more than a million Medicare patients with a GSM symptom, only 9 percent received a prescription.

Robbins shares that she had recurrent infections from her mid-twenties, two of which spread to her kidneys and put her in hospital, followed by years of dryness, urgency and leaking that ended in bladder surgery, and that she currently uses an estrogen patch and progesterone but nothing vaginal. Rubin responds that whole-body therapy often does not reach these tissues and that the guidelines say women on systemic hormones should still be screened and treated for GSM. She suspects Robbins's early infections were related to her birth control pill, and notes that a hormonal IUD does not shut down the ovaries the way the pill does.

Forms, cost and safety claims

Rubin shows the options. A generic estradiol cream costs, she says, about $13 cash for a tube lasting roughly two and a half months; one gram is rubbed inside the vagina twice a week. There is a 10-microgram insert used twice a week, and a ring left in place for three months, which she finds useful for busy patients and for women in nursing homes; she tells of a woman with advanced dementia who came off opioids after her pain turned out to be GSM. Vaginal DHEA is an alternative she likes because it supplies both estrogen and androgen, though it costs more. She says full benefit takes two to three months, and demonstrates vaginal pH paper, explaining that a reading of 4.5 or lower is the healthy range.

On safety she is emphatic. She says a 70-year-old's blood estrogen stays near zero on these products, and that "there's no one who can't have vaginal estrogen", including people with a history of breast cancer, citing a study of 50,000 women with breast cancer in which users had lower mortality. She frames the decision as shared between patient and doctor. She also concedes that more data are needed on younger women, and that an infection, once present, still needs a doctor, a culture and antibiotics. A prescription is currently required; she says the head of the FDA has expressed interest in over-the-counter access.

The boxed warning and a personal story

Until recently, Rubin says, all estrogen products, vaginal ones included, carried a boxed warning about stroke, blood clots, heart attack and probable dementia. She calls that warning false for vaginal hormones and describes a long campaign of letters and testimony that led the FDA to announce its removal.

She makes it personal. Her mother, a nurse, spent about six months in intensive care after a lung transplant. Rubin asked the team to continue her mother's vaginal estrogen to guard against a catheter-related infection, and was met at each step, from physicians to pharmacy to nurses, with the warning label. She ended up applying it herself and teaching her father and brother to advocate twice a week as staff rotated. She later told the FDA commissioner, "your box label tried to kill my mother". Her mother died that November; Rubin says the label's removal became official on what would have been her mother's birthday.

The Women's Health Initiative and the four buckets

Rubin traces the fear of hormone therapy to the 2002 Women's Health Initiative, when, she says, the NIH held a press conference before the paper was published declaring that hormones cause breast cancer and cardiovascular disease. Prescriptions collapsed overnight. Her account is that the data were misinterpreted and badly communicated, that the study tested a single pill and dose unlike today's patches and progesterone, and that some of the investigators objected to how it was presented. The lasting damage, she argues, is generations of clinicians never taught to prescribe; she says psychiatrists have told her their malpractice insurers would not cover it. Her conclusion: "there are no grownups coming to save the day".

She organizes therapy into four buckets: whole-body estrogen, mainly for hot flashes, night sweats and preventing osteoporosis; progesterone, which protects the uterine lining and may help sleep and mood; testosterone; and vaginal hormones, which are separate from the other three. A woman may use some or all. She is careful to add that not every medical problem is hormonal.

Testosterone for women

Rubin says of testosterone, "It is not a gendered hormone": ovaries and adrenal glands make it, and it declines from the thirties. Her repeated phrase is "it's not that serious". There is no FDA-approved testosterone product for women in the United States; she says a large trial showed benefit for libido but the agency asked for five more years of data around the time of the Women's Health Initiative and the effort died, while products are approved in Australia, New Zealand, South Africa and England and an international consensus paper supports its use.

In practice she checks a total testosterone level, and if it is not very high and the patient has symptoms, most often low libido, offers a trial using generic male gel at about one tenth of a man's dose: roughly half a milliliter rubbed on the leg daily, costing about $8 a month. She says effects usually appear after four to six months, and that patients report easier arousal and orgasm, better mood and some improvement in stress incontinence. The words she hears most are "I feel like myself again". She acknowledges that the strongest data concern libido. Possible side effects at higher doses include oily skin, acne and hair changes, and she is cautious about pellets because the dose cannot be removed once implanted. Testosterone's status as a controlled substance, a result of 1990s doping scandals, makes prescribing harder.

Clitoral adhesions and learning the anatomy

Rubin describes holding up a mirror during exams and naming each part, an approach featured in a 2022 New York Times article titled "Half the world has a clitoris. Why don't doctors study it?" by Rachel Gross, whose book Vagina Obscura she praises. Robbins, 57 and a mother of three, says no clinician has ever done this for her.

In 2017 Rubin's group reported that 23 percent of women seen in clinic had clitoral adhesions, in which the hood cannot be drawn back from the head of the clitoris. She compares the office procedure that releases it, done with numbing and no cutting, to clearing a crusted-shut eyelid. In a study of 41 patients she reports 76 percent improved arousal, 64 percent improved ability to orgasm, and that 38 percent of those who had never had an orgasm were able to afterward. She also describes a child whose years of pain were dismissed elsewhere and resolved after the adhesion was treated. She says more data are needed and that no specialty is trained to examine the clitoris.

Her anatomy lesson covers the pelvic floor, a bowl of muscle that can become too tight and cause constipation, urinary symptoms and painful sex, and that she says deserves rehabilitation with a pelvic floor physical therapist after childbirth; the outer and inner labia, the latter hormonally sensitive, which is why she urges caution about labiaplasty; the clitoris, whose internal legs extend beneath the labia, explaining why most women do not orgasm from penetration alone; and the vulvar vestibule, the thin ring of tissue around the vaginal and urethral openings. She calls pain there the most common reason for painful sex and describes a cotton swab test for it.

Pain with sex and getting care

"Sex should not be painful and you deserve a diagnosis", Rubin says. The two big causes she sees are hormonal change and tight pelvic floor muscles, which often occur together as the body guards against pain; a smaller group has nerve-related problems that sometimes need surgery. Just naming the problem and showing it to the patient is, she finds, powerful medicine in itself.

For a short appointment she recommends arriving educated and asking the clinician directly, "are you the right person to help me with these problems". She describes good care as a pit crew with the patient in the driver's seat, and blames ten-minute visits on the system and insurers more than on doctors. She points clinicians and patients to the International Society for the Study of Women's Sexual Health, the Menopause Society, and colleagues Heather Hirsch and Kelly Casperson.

Conclusion

Rubin's message is that many symptoms women dismiss as aging, stress or the price of sex are in her view treatable consequences of changing hormones, and that the tools are old, cheap and underused. She argues most strongly for low-dose vaginal hormones as a foundational, preventive therapy at any age, defends modern hormone therapy against the fears raised in 2002, presents testosterone as a reasonable option for women with bothersome low libido, and asks women to learn their own anatomy so they can describe problems precisely. Her claims are delivered as settled and are not contested on air, so listeners should treat the episode as an informed starting point for a conversation with a clinician, which is how she frames it herself: education first, then a team, with the patient making the decisions.

This is a summary of "The Ultimate Guide to Women’s Sexual Health, Hormone Replacement Therapy (HRT) & Menopause" from The Mel Robbins Podcast, giving you the GIST so you can decide if you want the REST. Listen to the full episode.