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

Peter Attia

May 12, 2025

Episode description

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Rachel Rubin is a board-certified urologist and one of the nation's foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women’s sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women’s Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women.

We discuss:

Rachel’s training in urology and passion for sexual medicine and women’s health [3:00];
Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women’s health and quality of life [5:30];
Why women have such varied responses to the sharp drop in progesterone during the luteal phase and after menopause, and the differing responses to progesterone supplementation [14:45];
The physical and cognitive health risks for postmenopausal women who are not on hormone therapy [17:45];
The history of hormone replacement therapy (HRT), and how misinterpretation of the Women’s Health Initiative study led to abandonment of HRT [20:15];
The medical system’s failure to train doctors in hormone therapy after the WHI study and its lasting impact on menopause care [29:30];
The underappreciated role of testosterone in women’s sexual health, and the systemic and regulatory barriers preventing its broader use in female healthcare [35:00];
The bias against HRT—how institutional resistance is preventing meaningful progress in women’s health [46:30];
How the medical

Mindsip insights from this episode:

Recognize estrogen-only HRT's role in reducing breast cancer risk

The controversial WHI study actually found that women on estrogen-only therapy had a decreased risk of both getting and dying from breast cancer, a fact that was ignored in the media.

#cancer

#estrogen

Recognize risks of skipping hormone therapy for menopausal health

We often focus on the risks of taking medication, but for menopausal women, the risks of not taking hormone therapy—such as osteoporosis, dementia, and recurrent UTIs—are significant.

#HRT

#menopause

Reframe menopause as a sudden hormonal shift

Menopause should be viewed not as a gradual decline but as a "castration event" where a woman's hormonal gas tank suddenly becomes empty.

#hormones

#menopause

Supplement systemic HRT with local vaginal estrogen for symptom relief

Even women on systemic hormone therapy often need additional local vaginal estrogen, as systemic treatment alone is frequently not enough to resolve genitourinary symptoms and prevent UTIs.

#HRT

#menopause

Dissolve oral estrogen sublingually for better absorption

A standard oral estrogen tablet can be dissolved under the tongue like a Tic Tac to bypass the liver, potentially avoiding negative effects on clotting factors and making it a cheap and effective delivery method.

#biohacking

#estrogen

Recognize women's testosterone dominance for better health understanding

When measured in the same units, women have about 10 times more testosterone than estradiol in their bodies, reframing them as testosterone-driven beings whose need for the hormone is often ignored.

#testosterone

#women

Revitalize menopause education to combat doctor training gap

The fallout from the WHI study created a "brain drain," leaving an entire generation of doctors untrained in prescribing hormone therapy, with less than 6% of relevant physicians today receiving even an hour of menopause education.

#education

#menopause

Address menopause to improve men's health outcomes

Menopause is a major contributor to divorce between the ages of 40 and 60, and since divorced or widowed men have significantly worse health outcomes, menopause is indirectly killing men.

#menopause

#relationships

Identify vulvar vestibule as source of menopausal pain

A little-known anatomical area called the vulvar vestibule, which is the female homolog to the male urethra, is often the true source of pain with sex and UTI-like symptoms in menopausal women.

#menopause

#pain

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